in  tfje  €itv  of  JSeio  §orfe^c>k>v/? 
^cijool  of  Bcntal  anli  0tal  ^urgerp 


i^efetente  l^itirarp 


General  Editor. — John   D.  Comkik 

M.A..  H.SC.  M.l)..   K.R.C.P.K, 


RADIOGRAPHY,  X-RAY  THERAPEUTICS 
AND  RADIUM  THERAPY 


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1.  Hahd  Condition.  .    ,r         r,        r, 

4.  \  KHY  Soft  Condition. 

Note  absence  of  blue  gas  iu  region  of  anode,  ,^^^  j.^.,^^  ,^i,^^  ^j^,^^  ^^^  ^           ^^^^^^^  ^j^^^  .^ 

also  sharply-cut  upper  limit  of  green  hemisphere.  ^^^  p,eceding  figure,  and  the  cathode  stream  is 

The    condition    indicates    absence    oi    reverse  more  evident 
current. 


5.  Reverse  Current  in  Circuit. 

2.  Normal  Condition.  The  appearance  of  the  tube  is  changed  entirely. 

The  hemisphere  has  lost  its  sharply-cut  appear- 

Note  faint  bine  cloud   in    region    of   anode.  ance  and  is  irregular.     The  faint  blue  cloud,  due 

Reverse  current  is  practically  absent.  to    gas    in  the    region  of  the    anode,   has    also 

changed,  and  the  upper  hemisphere  of  the  tube  is 
occupied  by  irregular  rings. 


o    c.        rt  6.  Polarity  Reversed. 

3.  Soft  Condition. 

T-,.',,         ij,        •  J        J-  The  cathode  has  become  the  anode  and  vice 

saxnt   blue   cloud  has  increased  and  is  novi^  xt  t    ti,      j.  c  iii,    i      i     r^-u 

, .      ,  ,        „,  I       •     1  •      J.-1,  versa.     Note  the  stream  of  gas  at  the  back  of  the 

very  noticeable.     The  green  hemisphere  is  still  ,    ,  i  iu    -u  •  -u*        ,.  ^  ^^  -j. 

,    •^   ,  .      V    .         J-  ,•     i.        JL    1        i  tube  and  the  bright  spot  on  glass  wall  opposite 

sharply    cut,    but    a    distinct    cathode    stream  ,     i-.  ,■      j.-u    i         i      xt       -u  / 

'^  •'   ,    ,   '        ,,         . ,     -,         1       4.-      i.1     1  to  the  anti-cathode  :  also  the  absence  of  gi'een 

appears  between  the  catliode  and  anti-cathode.  i,      •     -u 

^^  hemisphere. 


Appearances  of  X-Ray  Tube  in  Action. 
(Reproduced  from  coloured  drawings  kindly  lent  by  Mr.  C.  Andrews.) 


RADIOGRAPHY 
X  RAY  THERAPEUTICS 


AXD 


RADIUM   THERAPY 


BY 

ROBERT    KNOX 

M.D.  (Edin.),  M.R.C.S.  (Eng.),  L.R.C.P.  (Lond.) 

HON.   RADIOGRAPHER,    KINg's  COLLEGE  HOSPITAL,    LONDON 

DIRECTOR,   ELECTRICAL  AND  RADIOTHERAPEUTIC  DEPARTMENT,   CANCER  HOSPITAL,   LONDON 

HON.    RADIOGRAPHER,    GREAT  NORTHERN  CENTRAL  HOSPITAL,  LONDON 

CAPTAIN   R.A.M.C.    (t.)  4<TH   LONDON  GENERAL  HOSPITAL  (iN  CHARGE  OF  X-RAY  DEPARTMENT) 


WITH  SIXTY-FOUR  PLATES 

TWO  HUNDRED  AND  FORTY-SIX  ILLUSTRATIONS  IN  THE  TEXT 

AND  A  FRONTISPIECE  IN  COLOUR 


i^eto  |9orfe 
THE  MACMILLAN  COMPANY 

1915 

A II  rights  reserved 


vf 


TO 

ALEXANDER  MORISON 

M.D.  (Edix.),  F.R.C.P.  (Loxd.  axd  Edix.) 

IN  RECOGNITION  OF  THE  VALUABLE  HELP  AND  KINDLY 

ENCOURAGEMENT   FREELY   RENDERED    THROUGH   MANY 

YEARS    OF    CLOSE    ASSOCIATION 


PEEFACE 

The  object  of  this  work  is  to  present  to  the  student  and  practitioner  in  as 
concise  and  practical  a  form  as  possible  the  essential  points  in  radiography. 
X-ray  therapeutics,  and  radium  therapy.  The  chief  aim  throughout  has  been 
to  present  these  leading  features  in  such  a  form  that  the  beginner  may 
easily  acquire  a  working  knowledge  of  radiography,  radiation  technique, 
and  therapy.  The  book  is  therefore  a  practical  one,  theoretical  considera- 
tions having  been  omitted  as  far  as  possible. 

The  section  on  radiography  has  been  illustrated  as  fully  as  possible, 
care  having  been  taken  to  select  only  illustrations  which  have  a  definite 
educational  value.  Much  attention  has  been  paid  to  important  points  in 
the  practical  working  of  apparatus,  and  it  is  hoped  that  the  student  mil  be 
carried  from  the  technical  details  to  a  consideration  of  results  obtained,  and 
their  bearing  on  the  diagnosis  of  diseases.  For  this  purpose  a  number  of 
anatomical  and  pathological  diagrams  have  been  incorporated  in  the  text, 
and  I  would  like  gratefully  to  acknowledge  the  valuable  data  gathered  from 
well-known  works  on  anatomy,  pathology,  medicine,  and  surgery.  The 
following  books  have  been  freely  used  in  the  compilation  of  the  text :  Gray's 
Anatomy,  Heath's  Anatomy,  Cunningham's  Anatomy,  Holden's  Osteology, 
Rose  and  Carless's  Surgery,  Erichsen's  Surgery,  Allbutt's  System,  of  Medicine, 
Osier's  Practice  of  Medicine,  and  many  others. 

I  also  wish  to  acknowledge  the  valuable  help  obtained  from  a  number 
of  electrical  firms,  and  personally  to  thank  Mr.  Howard  Head  for  reading 
and  correcting  the  section  on  instrumentation,  and  for  compiling  a  glossary 
of  terms  used  in  medical  electricity.  My  thanks  are  also  due  to  Mr.  Schall 
for  permission  to  print  passages  from  his  admirable  descriptions  of  methods 
of  measurement  of  X-rays,  to  Mr.  Geoffrey  Pearce  for  preparing  several 
drawings  of  apparatus,  and  to  Mr.  Andrews  for  many  valuable  suggestions 
regarding  the  X-ray  tube  and  its  manipulation. 

I  am  also  indebted  to  Mr.  Thurstan  Holland  for  several  valuable  prints, 
and  for  many  hints  on  radiographic  technique.  Dr.  E,.  W.  A.  Salmond  has 
contributed  several  interesting  prints,  and  has  rendered  some  assistance  in 

vii  h 


viii  KADIOGEAPHY 

the  preparation  of  parts  of  the  text.  My  thanks  are  also  due  to  Mr. 
E.  H.  Shaw,  pathologist  to  the  Great  Northern  Central  Hospital,  for 
help  in  the  descriptions  of  sections  from  tumours  treated  by  radiations. 
Mr.  A.  H.  Booker  has  been  responsible  for  the  preparation  of  the  greater 
part  of  the  prints  from  which  the  illustrations  have  been  taken  and  also  for 
the  excellent  micro-photographic  work. 

For  the  section  on  Kadium  Therapy  Mr.  C.  E.  S.  Phillips,  F.R.S.E.,  has 
been  good  enough  to  write  a  special  article  on  the  Physics  of  Radium. 

I  must  also  thank  most  heartily  the  General  Editor,  Dr.  John  D.  Comrie, 
for  in  the  first  instance  suggesting  the  book  and  then  for  indicating  the 
combination  of  the  allied  subjects  to  be  included  in  it ;  also  for  many 
valuable  suggestions  during  the  preparation  and  progress  of  the  book.  The 
idea  of  producing  the  plate  illustrations  in  negative  and  positive  is  entirely 
his,  and  adds  greatly  to  their  value. 

I  am  also  greatly  indebted  to  my  old  friend  Alexander  Mackay,  B.A., 
for  valuable  help  in  arranging  the  text  and  correcting  the  proofs. 

The  index  has  been  prepared  by  Mr.  H.  A.  Low,  and  I  gratefully  acknow- 
ledge the  invaluable  assistance  that  he  has  given  me  at  all  times ;  I  wish 
also  to  express  my  appreciation  of  his  unfailing  courtesy  during  many  hours 
of  close  association. 

Thanks  are  also  due  to  my  colleagues  at  the  Cancer  Hospital,  King's 
College  Hospital,  and  the  Great  Northern  Central  Hospital,  for  their  help, 
always  most  readily  given,  on  the  many  difficult  points  in  diagnosis  which 
are  constantly  encountered,  and  for  the  great  help  they  have  given  in  follow- 
ing up  cases  in  which  a  radiographic  diagnosis  has  been  confirmed  or  other- 
wise in  the  operating  room.  The  value  of  such  confirmation  or  negation 
is  very  great,  as  it  enables  the  radiographer  to  verify  his  observations  on 
debatable  and  doubtful  points,  and  renders  the  help  he  is  able  to  give  the 
physician  or  surgeon  of  much  greater  value.  The  importance  of  this  co- 
operation is  referred  to  in  the  text,  and  I  consider  it  indispensable  if  the  full 
value  of  the  methods  described  in  this  book  is  to  be  obtained. 

It  is  impossible  to  thank  adequately  all  those  who  have  assisted  me  in 
the  production  of  the  numerous  plates  which  make  up  the  list  of  illustrations, 
but  I  would  like  to  tender  my  cordial  thanks  to  the  members  of  the  Assistant 
and  Nursing  Staffs  of  the  Great  Northern  Central  Hospital,  the  Cancer 
Hospital,  and  King's  College  Hospital,  all  of  whom  have  contributed  to  the 
whole,  and  without  whose  loyal  and  keen  interest  and  help  this  work  could 
not  have  been  produced. 

ROBERT  KNOX. 

7  Harley  Street,  W. 


CONTENTS 


PART  L— RADIOGRAPHY 

PAGE 

Sources  of  Electric  Energy  .......    3-27 

Continuous  current  supply — Alternating  current  supply^ — Apparatus  for 
heavy  discharges — Apparatus  for  the  production  of  single-impulse  radio- 
graphs— Accumulators — Dynamos — ^Motor  transformers — The  induction  coil 
— The  control  apparatus — The  interrupter — Summary. 

X-Ray  Tubes  and  their  Accessories  ......  28-61 

The  focus  tube — Suppression  of  reverse  (inverse)  current — Instruments  for 
estimating  the  hardness  of  the  X-ray  tube. 

Tube  Stands,  Couches,  Compressors,  and  Screening  Stands  .  .  62-79 

The  X-ray  tube-stand — Couches  and  stands. 

The  Arrangement  of  Apparatus       .......  80-90 

A  small  installation — Installation  for  a  general  hospital  or  consulting  radio- 
logist— Installation  for  a  special  hospital — Installation  for  a  base  hospital  for 
military  service. 

Production  of  the  Radiograph        ......  91-104 

The  plate  or  film  employed — Exposure — The  placing  of  photographic 
plates — The  use  of  the  intensifying  screen — Development — Fixing — Washing 
and  drying — Reduction — Intensification — Printing — Further  points  in  ex- 
posure and  development — Instructions  for  glazing  gelatino-chloride  prints. 

Stereoscopic  Radiography      .  .  .  .  .  .  .  105-106 

The  Localisation  of  Foreign  Bodies         .....  107-122 

Localisation  of  foreign  bodies  in  special  locaUties. 

Radiography  of  the  Normal  Bones  and  Joints  .  .  .  123-137 

The  skull  and  accessory  sinuses — The  cervical  region — The  bones  of  the 
chest — The  dorsal  spine — The  lumbar  spine — The  pelvis — The  upper  ex- 
tremity— The  lower  extremity. 

The  Development  of  the  Bones      .  .  .  .  .  .  138-153 

Pi,adiographic  survey  of  the  joints  showing  epiphyses. 

IX 


X  EADIOGEAPHY 

PAGE 

Injubies  op  Bones  and  Joints  ......  154-166 

Injuries  of  the  skull  and  spine — Fracture  of  the  ribs — Fracture  of  the 
clavicle — Fracture  of  the  scapula — Fractures  of  the  humerus — Injuries  in  the 
region  of  the  elbow- joint — ^Fracture  of  the  shaft  of  the  radius  and  ulna — 
Injuries  at  the  wrist-joint — Fractures  of  the  bones  of  the  hand — Fractures  of 
the  pelvis — Injiu-ies  near  the  hip-joint — Fractures  of  the  femur — Fractures  of 
the  patella — Fractures  of  the  bones  of  the  leg — Fractures  in  the  neighbourhood 
of  the  ankle-joint. 

Diseases  of  Bone  ........         167-173 

Classification  of  inflammatory  affections  of  bone. 

Diseases  of  Joints         ........         174-178 

Tuberculous  disease  of  joints — Chronic  articular  rheumatism — Chronic 
articular  gout — Loose  bodies  in  joints — Rheumatoid  arthritis  or  rheumatic 
gout — Hypertrophic  arthritis  or  osteoarthritis — Charcot's  joints. 

Differential  X-Ray  Diagnosis  in  Diseases  of  Bones  and  Joints  .         179-187 

Tumours    of    bone — Appearance    of    joints    in    tuberculosis — Tubercular 
.  dactyhtis — SyphiUtic  dactylitis — SyphiUs  of  bone — Chronic  infective  osteo- 
myehtis — Acute  osteomyeUtis — ^Acute  infective  periostitis — Tumours  of  bone 
— Carcinoma  of  bone — Differential  diagnosis  of  tumours  of  bone. 

The  X-Ray  Examination  of  the  Thorax  and  its  Contents  .  .         188-208 

Radioscopy — Radiography — Diseases  of  the  thorax — Differential  diagnosis 
in  diseases  of  the  lungs — The  examination  of  the  heart  and  aorta. 

The  X-Ray  Examination  of  the  Alimentary  System  .  .  .         209-234 

The  examination  of  the  oesophagus — Examination  of  the  stomach — Ex- 
amination of  the  small  intestine — Examination  of  the  large  intestine — 
Foreign  bodies  in  the  ahmentary  canal. 

The  X-Ray  Examination  of  the  Urinary  Tract  .  .  .         235-247 

Technique — Anatomical  relations  of  the  urinary  organs — Diseases  of  urinary 
tract  including  calculi — Technique  of  the  examination  of  the  urinary  system 
with  coUargol  solution. 

Congenital  Malformations   ........     248 

PART  II.— RADIATION   THERAPEUTICS 

Introductory       .........         251-264 

Action  of  radiation  upon  tissues — Action  of  radiations  on  normal  tissues  and 
morbid  growths — Dangers  attendant  on  the  use  of  X-rays  and  radium. 

A.  X-EAY  THEKAPEUTICS 
Special  Points  in  Instrumentation  .....         265-297' 

Methods  of  protection — Arrangement  of  apparatus — Methods  used  in 
estimation  of  dosage — Arrangements  for  exposure — Development — The  use 
of  filters — The  choice  of  the  X-ray  therapeutic  tube. 


CONTENTS 

The  Treatment  of  Diseases  of  the  Skin  . 

The  Treatment  of  Enlarged  Lymphatic  Glands 

The  Treatment  of  Rodent  Ulcers  .... 

The  Treatment  of  Sarcomata  .... 

The  Treatment  of  Carcinomata       .... 

The  Treatment  of  Enlargement  of  the  Prostate  Gland 

The  Treatment  of  Exophthalmic  Goitre  . 

The  Treatment  of  Uterine  Fibromata 

The  Treatment  of  Diseases  of  the  Blood 

The  Treatment  of  Diseases  of  the  Lungs  and  Mediastinum 


XI 

PAGE 

298 
307 
309 
312 
312 
316 
317 
318 
323 
.327 


B.  RADIUM  THERAPY 

Physics  op  Radium.     By  C.  E.  S.  Phillips,  F.R.S.E.      .  .  .         329-344 

lonisation  and  recombination — Radium  emanation — ^Measurement — 
Physiological  action. 

The  Practical  Application  of  Radium  to  Disease        .  .  .         345-353 

Methods  of  using  radium — Filtration  of  radium  rays — Radium  tubes  in  the 
substance  of  a  tumour — Treatment  of  deep-seated  tumours  by  external 
applications. 

Dosage  in  Radium  Therapy    ........  353 

Relation  between  the  value  of  radium  and  its  activity. 

Radium  in  General  Diseases             .......  357 

Radium  in  Diseases  of  the  Eye       .......  359 

Radium  in  Diseases  of  the  Ear,  Nose,  and  Throat     ....  359 

Radium  in  the  Treatment  of  Exophthalmic  Goitre     ....  360 

Radium  in  the  Treatment  of  Malignant  Disease  of  the  Thyroid  Gland  360 

Radium  in  the  Treatment  of  Diseases  of  the  Skin     ....  361 

Radium  in  Gynecological  Practice           ......  365 

Radium:  in  Superficial  Epithelioma  and  Rodent  Ulcer         .           .           .  368 

Radium  in  Infiltrating  Epithelioma          ......  370 

Radium  in  Sarcomata  and  Carcinomata     .  .  .  .  .  .371 

Radium  in  Cancer  of  the  Tongue  and  Mouth    .....  373 

Radium  in  Cancer  of  the  OEsophagus        ......  374 

Radium  in  Cancer  of  the  Rectum,  the  Prostate  Gland,  and  the  Bladder  375 


C.  RADIUM  AND  X-RAYS 
The  Combined  Use  in  Malignant  Disease 


.     378 


GLOSSARY 
INDEX       . 


.     387 
.     391 


LIST   OF   ILLUSTRATIONS 


FULL-PAGE  PLATES 


All  the  radiographic  illustrations  in  the  plates  have  been  reproduced  in  negative 
and  positive  form,  the  object  being  to  present  the  reader  with  what  is  actually  seen 
when  a  negative  and  positive  are  examined.  When  comparing  the  two  side  by  side  it 
will  be  seen  that  the  one  is  complementary  to  the  other.  For  convenience  of  com- 
parison the  negative  and  positive  have  been  reproduced  from  the  same  aspect ;  in  actual 
practice  the  one  is  the  reverse  of  the  other. 


Appearances  of  X-Ray  Tube  in  Action  {in  colour) 

I.  Normal  Skulls         ..... 
n.  Normal  Skulls        ..... 
ni.  Skulls  showing  Departures  from  the  Normal 
IV.  Lower  Jaw  and  Cervical  Region 
V.  Normal  Lumbar  Spine  and  Pelvis 
VI.  Normal  Shoulder- joint        .... 
vn.  Normal  Elbow  and  Fractui-es  in  Region  of  Elbow- joint 
vm.  Normal  Knee-joint  .... 

IX.  Showing  Epiphyses  of  Hip,  Knee,  and  Ankle-joints 

X.  Fractures  in  Region  of  Shoulder- joint     . 

XI.  Fractures  in  Region  of  Shoulder-joint    . 
xn.  Fractures  in  Region  of  Elbow- joint 

xm.  Fractures  in  Forearm,  Wrist,  and  Hand 
XIV.  Fractures  at  Wrist-joint      .... 
XV.  Fractures  of  Wrist  and  Hand    . 
XVI.  Normal  ffip.  Dislocation,  and  Fracture  at  Hip-joint 
xvn.  Injuries  and  Disease  of  Pelvis  and  Hip-joint   . 
xvni.  Injuries  at  Knee-joint        .... 

XIX.  Fractures  of  Bones  of  Leg 

XX.  Fractures  at  the  Ankle-joint 
XXI.  Fractures  of  Leg,  Ankle,  and  Foot 

XXII.  Chronic  Inflammatory  Conditions  of  Bones 
xxni.  Inflammatory  and  other  Affections  of  Bones    . 

xiii 


FAC 


Frontispiece 

!G  PAGE 

124 
126 
128 
129 
133 
135 
138 
140 
147 
156 
158 
161 
162 
163 
164 
166 
167 

Between 
168  &  169 

170 
171 


FACING  PAGE 


xiv  RADIOGEAPHY 

FACING 

XXIV.  Tubercular  Disease  of  the  Hip-joint  .....     173 

XXV.  Tubercular  Disease  of  other  Joints    .  .  .  .  .  .174 

XXVE.  Tuberculosis  of  Bones  and  Joints      .  .  .  .  .  .175 

xxvn.  Chronic  Arthritic  Changes  at  the  Knee-joint  ....      176 

xxvin.  Diseases  and  Curvature  of  the  Spine  .  .  .  .  .179 

XXIX.  Tuberculosis  of  Bones  and  Joints      .  .  .  .  .  .181 

XXX.  Tumours  of  Bone  ........      183 

XXXI.  Tumoxirs  of  Bone  ........      186 

xxxn.  Mahgnant  Diseases  of  the  Chest         ......      188 

xxxm.  Chest  showing  Pleural  Effusion  and  its  Absorption  .  .  .      190 

XXXIV.  Chests  showing  Pulmonary  Tuberculosis      .....     194 

XXXV.  Chests  showing  Pulmonary  Tuberculosis      .....      197 

XXXVI.  Chests  showing  Secondary  Carcinoma  .....     199 

xxxvn.  Chests  showing  Changes  in  Heart  and  Lungs         •  •  •  .     201 

xxxvrn.  Chest  showing  Chronic  Pleurisy  with  Bi-lateral  Effusion  .  .     202 

XXXIX.  Chests      ..........     204 

XL.  Chests  showing  Aneurism  and  New  Growth  ....     207 

XLi.  Chest  showing  Dilatation  of  CEsophagus       .  .  .       ■     .  .211 

XLH.  Stomach  showing  Pyloric  Stenosis     .  .  .  .  .  .213 

XT.TTT.  Stomach  and  Colon  showing  Visceroptosis  .....     218 

XLiv.  Stomach  and  Colon  showing  Visceroptosis   .....     220 

XLV.  Opaque  Meal  in  Stomach  and  Colon  .....     222 

XLVi.  Hour-glass  Contraction  of  the  Stomach        .....     226 

XLvn.  Stomach  showing  Obstruction  at  Pylorus     .  .  .  .  .231 

XLvrn.  Opaque  Enema  in  Colon  .......     234 

XLix.  Urinary  Calcuh  .........     241 

L.  Tuberculosis  of  Eadney  and  Mesenteric  Glands       ....     243 

LI.  Urinary  CalcuK  and  Gallstones  ......     244 

LH.  Kidneys,  Ureter,  and  Bladder  ......     245 

Lm.  Dermoid  Cyst  in  Pelvis  .......     246 

Liv.  Congenital  Deformities  ...  =  ...     248 

Lv.  Changes  produced  in  Normal  Tissues  by  Radiations  .  .  .     254 

Lvi.  Changes  observed  in  Tumours  which  have  been  treated  by  Radiations      256 

Lvn.  Changes  observed  in  Tumours  which  have  been  treated  by  Radiations      258 

Lvm.  Changes  observed  in  Tumours  which  have  been  treated  by  Radiations      260 

Lix.  Rodent  Ulcers,  treated  with  Radium,  X-Rays,  and  CO2  .  •  .     309 

LX.  Cases  of  Rodent  Ulcers  treated  with  Radium         .  .  .  .311 

LXi.  Carcinomata  treated  by  X-Rays        .  .  .  .  .  .314 

Lxn.  Stages  in  the  treatment  of  an  Atrophic  Scirrhus  Cancer  of  the  Breast       316 
LXTTT.  Rodent  Ulcers  treated  with  Radium  and  X-Rays  .  .  .     368 

LXiv.  Recurrent  Carcinoma  after  Removal  of  Breast       ....     372 


LIST  OF  ILLUSTRATIONS 


XV 


ILLUSTRATIONS  IN  THE  TEXT 

FIG. 

1.  Gaiffe  Rochefort  outfit  for  alternating  current 

2.  Alternating  current  high-tension  rectifier 

3.  Single-impulse  outfit,  showing  switch,  and  switch-table  with  time  relay 

4.  Snook  apparatus 

5.  Diagram  of  Snook  apparatus 

6.  Accumulator  connections 

7.  Gas  engine  and  dynamo 

8.  Induction  coil 

9.  Plan  of  winding  of  coil,  primary  and  secondary,  with  connection  to  condeaser 

and  break     ..... 

10.] 

/Connections  of  the  X-ray  tube  to  the  coil 
11 J 

12.  Diagram  to  illustrate  construction  of  a  centrifugal  mercury  interrupter 

13.  Plan  of  connections  for  Dreadnought  interrupter 

14.  Dreadnought  interrupter        .... 

15.  Dreadnought  interrupter  showing  detail     . 

16.  Instanta  interrupter   ..... 

17.  Sanax  interrupter        ..... 

18.  Improved  Mackenzie  Davidson  interrupter 

19.  Single-point  electrolytic  interrupter 

20.  Three-point  electrolytic  interrupter 

21.  Single-point  electrolytic  interrupter 

22.  Trolley  control  table,  with  resistances  arranged  to  facilitate  time  and  rapid 

exposures 

23.  Larger  view  of  top  of  trolley  control  table  to  show  the  regulating  parts 

24.  GaifEe  interrupter        .... 

25.  Diagram  of  an  X-ray  tube  with  parts  named 

26.  Radiator  tube  constructed  for  heavy  discharges 

27.  Cyclops  radiator  tube 

28.  Water-cooled  tube  arranged  for  overhead  work 

29.  Water-cooled  tube  for  overhead  or  under  the  couch  work,  showing  mica  and 

carbon  regulator      ...... 

30.  Dessauer  tube  with  atomiser  for  cooKng  the  anti-cathode 

31.  Heavy  anode  tube.     Osmosis  regulator 

32.  CooHdge  X-ray  tube  ..... 

33.  Details  of  CooHdge  tube        ..... 

34.  Complete  Coolidge  X-ray  equipment  in  position  . 

35.  Diagram  of  connections  for  Coolidge  tube 
36. 
37 


"  I  Connections  of  the  X-ray  tube  to  the  coil 


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XVI 

Fig. 

38. 
39. 
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42. 
43. 
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76. 
77. 

78. 
79. 


RADIOGRAPHY 

Connection  of  X-ray  tube  to  the  coil 

Manipulation  of  the  X-ray  tubes 

Mca  regulator 

Bauer  air- valve 

Gundelach  regeneration 

Spark-gap 

Single  valve  tube 

Triple  valve  tube 

French  valve  tube 

Oliver  Lodge  valve  tube 

Gundelach  valve  tube 

Oscilloscope  tube 

Oscilloscope  tube  in  action 

Diagram  showing  the  paths  taken  by  primary  beams  and  secondary  rays 

Diagram  showing  the  use  of  a  diaphragm  between  tube  and  plate 

Diagram  showing  the  use  of  a  cylinder  diaphragm 

Adjustable  spintermeter         .... 

Bauer  qualimeter        ..... 

Walter's  radiometer    ..... 

Benoist  radiometer      ..... 

Protected  front  for  Fig.  57    . 

Wehnelt's  crypto -radiometer 

Milhamperemeter        ..... 

PUlar  stand,  protected  tube-box,  and  accessories 

A  form  of  tube-stand  .... 

A  convenient  type  of  tube-stand  with  iris  diaphragm 

Tube-box  with  extension  tube 

Tube-box  with  rectangular  diaphragm 

A  convenient  form  of  X-ray  couch 

Albers-Schonberg  compressor 

A  couch  fitted  with  protected  tube-box  underneath 

Extension  tube  of  a  kidney  compressor  to  show  method  of  compression 

Screening  stand  arranged  for  stereoscopic  work  in  the  upright  position 

Screening  stand  arranged  for  work  beneath  the  table     . 

Screening  stand  arranged  for  examinations  in  the  upright  position 

Screening  stand  arranged  to  work  as  a  compressor 


Wenckebach  screening  stand  ...... 

A  useful  form  of  universal  examining  chair  .... 

Examining  chair  fitted  with  mechanical  movements  to  facHitate  the  rapid 
manipulation  of  the  patient  ...... 

A  convenient  form  of  apparatus  arranged  on  an  upright  cabinet 
Diagram  to  illustrate  the  parts  as  arranged  in  Fig.  78  . 


PAGE 

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81 
81 


LIST  OF  ILLUSTRATIONS  xvii 

80.  Plan  for  consulting-room  or' hospital  outfit         .... 

81.  Plan  of  the  X-ray  and  electrical  defjartments  at  King's  College  Hospital 

82.  Plans  of  the  electrical  department  at  the  Cancer  Hospital,  Fulham  . 

83.  Portable  X-ray  installation  arranged  for  radiography  from  Vjeneath  couch 

84.  Portable  X-ray  installation  packed  ready  for  transit    . 

85.  Slide  rule        ......... 

86.  Normal  hand  to  illustrate  value  of  an  intensifying  screen 

87.  Radiogram  to  illustrate  the  latitude  of  exposure 

88.  Radiogram  to  illustrate  the  latitude  of  exposure 

89.  Wheatstone  stereoscope       ....... 

90.  Pirie  stereoscope        ........ 

91.  Diagram  to  show  method  of  taking  a  lateral  view 

92.  Diagram  showing  Mackenzie  Davidson  method 

93.  Mackenzie  Davidson  cross-thread  locahser  .... 

94.  Diagram  to  illustrate  simple  formula  for  locaUsing 

95.  Diagram  to  illustrate  Mackenzie  Davidson's  short  method  of  locaUsation 

96.  Graduated  scale  in  Hampson  locaUser      .  .  .  .  • 
96a.  Hampson  locahser,  diagram  to  illustrate  method 

97.  BuUet  in  brain.     Fragments  in  face  ..... 

98.  Fractm-e  of  lower  jaw  ;  foreign  body  in  soft  parts  ;  a  portion  of  shrapnel  above 

the  jaw  bone  .... 

99.  Fragment  of  shell  in  region  of  hip-joint  . 

100.  Fracture  of  tibia,  portions  of  shell  in  Umb 

101.  Fragments  of  bullet  in  hmb 

102.  Fragments  of  shrapnel  in  hand 

103.  Arrangement  of  X-ray  tube  and  fluorescent  screen 

104.  Sweet  locahser  ...... 

105.  Dr.  M.  Berry's  chair  for  frontal  sinuses,  etc. 

106.  Position  for  radiography  of  the  mastoid  sinuses 

107.  Chair  for  cranial  radiography         .... 

108.  Chair  for  cranial  radiography,  with  patient  in  position 

109.  Upper  cervical  region,  antero-posterior  view 

110.  Normal  cervical   and   upper   dorsal  region   showing  the   sterno-clavicular 

articulation  .... 

111.  Showing  bones  at  ankle  and  foot  with  epiphyses,  and  dates  at  which  they 

unite  with  the  diaphyses  .... 

112.  Foot 

113.  Diagram  to  show  the  epiphyses  entering  into  the  knee-joint 

114.  Diagrams  to  illustrate  the  appearances  of  the  epiphyses  at  the  knee-jouit, 

traced  from  radiographs  ....... 

115.  Lateral  view  of  knee-joint,  showing  epiphyses    .... 

116.  Antero-posterior  view  of  knee-joint  showing  epiphyses 

117.  Fracture  of  tibia  and  fibula  ...... 

118.  Diagram  to  show  the  epiphyses  and  bones  entering  into  the  hip- joint 


83 

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88 

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93 

96 

102 

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108 

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112 

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119 

120 
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126 
127 
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130 

131 

144 
146 
145 

146 
146 
147 
147 

147 


xviii  EADIOGRAPHY 

Fig. 

119.  Pelvis  and  femora  of  a  child  two  days  old,  showing  ossification  of  bones  of 

pelvis,  hip,  and  knee  joints         ....... 

120.  Diagram  showing  the  bones  forming  the  wrist-joint  and  joints  of  the  finger 

121.  Hand  of  a  child  over  five  years  old  .... 

122.  Shows  stage  of  ossification  in  a  young  adult  imder  twenty  years 

123.  Diagram  showing  epiphyses  of  the  bones  forming  the  elbow-joint 

124.  Elbow-joint,  antero-posterior  view,  shows  epiphyses.     Age  14 

125.  Lateral  view  of  elbow-joint,  to  show  epiphyses.     Age  14 

126.  Diagram  to  show  bones  entering  into  the  shoulder- joint 

127.  Normal   shoulder-joint   showing    condition    of   epiphyses    at   the    head   of 

humerus       ..... 

128.  Shoulder-joint,  showing  epiphyseal  line    . 

129.  Comminuted  fracture  of  angle  of  lower  jaw 

130.  Fracture  through  ramus  of  lower  jaw 

131.  Fracture  dislocation  of  cervical  vertebrse 

132.  Fractures  of  vertebral  border  of  scapula  and  three  ribs  (gunshot  woimd) 

133.  Fracture  of  shaft  of  radius  and  upper  end  of  ulna  (gunshot  wound) 

134.  Fracture  of  lower  end  of  humerus,  with  backward  displacement  of  the  lower 

fragment     .... 

135.  Fracture  of  shaft  of  humerus  ;  rotation  of  lower  fragment  and  elbow- joint 

136.  Fracture  through  external  condyle  with  forward  and  upward  displacement 

of  the  fragment  of  bone  ..... 

137.  Dislocation  of  elbow- joint    ..... 

138.  Fractures  through  shafts  of  radius  and  uLna 

139.  Fracture  of  shaft  of  uLna  (the  result  of  a  gunshot  wound) 

140.  Fracture  through  shafts  of  both  femora  . 

141.  Fracture  of  os  calcis  (gunshot  wound) 

142.  Typhoid  osteitis  and  periostitis  resulting  in  an  abscess 

143.  Elbow-joint  showing  disease  .... 

144.  Wrist  and  hand  of  child,  showing  changes  in  lower  end  of  radius  and  ulna  due 

to  rickets    ........ 

145.  Tuberculosis  of  left  hip- joint,  particularly  affecting  the  acetabulum 

146.  Arthritis  following  injury  of  knee-joint.     Lateral  view 

147.  Sarcoma  of  lower  end  of  femur 

148.  Chondro-sarcoma  of  lower  end  of  tibia 

149.  Sarcoma  at  upper  end  of  humerus 

150.  Tumour  of  clavicle    . 

151.  Exostosis  of  lower  end  of  femur    . 

152.  Traumatic  myositis  ossificans 

153.  Upright  screening  stand  with  automatic  stereoscopic 

and  plate-holder  controlled  from  the  switch-board 

154.  Thorax  of  an  adult  ..... 

155.  Normal  lower  cervical  and  upper  dorsal  vertebrae,  showing  the  position  for 

demonstration  of  cervical  ribs  and  apices  of  the  lungs 


movements  of  tube 


148 
149 
149 
150 
150 
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151 
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152 
152 
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189 
190 

191 


Fif). 

156. 

157. 

158. 

159. 
160. 
161. 

162. 

163. 
164. 

165. 
166. 
167. 
168. 
169. 

170. 
171. 
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174. 
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176. 
177. 
178. 
179. 
180. 
181. 

182. 
183. 
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185. 
186. 
187. 
188. 
189. 
190. 
191. 
192. 


LIST  OF  ILLUSTRATIONS 

Position  of  thorax  for  lateral  oblique  position,  to  show  position  of  plate  and 

source  of  X-rays    ......... 

Diagram  to  illustrate  the  appearance  of  thorax  in  semi-lateral  position 
Diagrams    (after   Holzknecht)    to   illustrate   points   of   difference    between 

dilated  aorta  and  an  aneurism   ••..... 
Diagram  to  show  the  position  for  lateral  obhque  examination  of  the  thorax 
Diagrammatic  representation  of  the  lateral  view  of  thorax 
Appearances  seen  on  fluorescent  screen  after  patient  has  taken  bismuth  food 

shown  diagrammatically  ........ 

Diagram  to  illustrate  the  appearance  seen  in  a  semi-lateral  view  of  the 

thorax  •••••-.... 

Diagram  from  a  text-book  of  anatomy  shomng  position  of  stomach 
The  position  of  the  empty  stomach.     Diagrammatic  representation  of  the 

screen  examination  •••..... 

Diagrams  showing  stages  of  filling  of  stomach  by  opaque  meal 

Diagrams  to  illustrate  the  stages  of  a  bismuth  meal     .... 

Types  of  stomach      ........_ 

Diagram  to  show  position  of  stomach  in  jatosis  .... 

Diagrammatic    representation   of    pyloroptosis,    viith   some    atony   of   the 

stomach       ••••...... 

Diagram  to  represent  a  condition  met  with  in  examination  of  the  stomach 
Hour-glass  stomach  ......... 

Hour-glass  contraction  of  the  stomach     ...... 

Three  examples  of  carcinoma  of  the  stomach     ..... 

Illustrating  the  appearances  seen  in  carcinoma  at  pyloric  end  of  stomach 
Situations  of  tumour  of  stomach   ....... 

Opaque  meal  in  ileum  and  caecum,  five  hours  after  ingestion 

Same  case  at  a  later  stage,  ten  hours  after  ingestion    .... 

Diagrammatic  representation  of  colon  filled  with  bismuth  food 

Couch  fitted  with  kidney  compressor        ...... 

X-ray  couch  to  illustrate  method  of  compression  .... 

Diagram  to  illustrate  the  "  areas  "  to  be  examined  in  radiography  of  the 

urinary  tract  .... 

Kidney  area,  showing  stone  in  left  kidney 
Stone  in  ureter 
Large  stone  in  the  bladder 
X-ray  treatment  cubicle 
IVIilliamperemeter 
Bauer  qualimeter 

Therapeutic  outfit  suitable  for  deep  therapy 
Mercury  interrupter  with  gas  di-electric  . 
Mercury  interrupter  showing  details 
Dipping  interrupter  with  revolution  counter 
Morton  rectifier  fitted  to  a  coil  outfit  with  control  table 


XIX 

I'AfiE 

206 
206 

207 
210 
211 

211 

211 
212 

212 
213 
217 
220 
223 

223 
225 
226 
226 
228 
228 
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230 
231 
232 
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239 
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243 
266 
267 
268 
269 
270 
270 
271 
272 


XX  RADIATION  THERAPEUTICS 

Fig. 

193.  Diagram  of  connections  for  Morton  rectifier        .....  273 

194.  Triple  valve  tube      .....••••  273 

195.  Method  of  connecting  coil  to  valve  tube  and  X-ray  tube.     Valve  tube  on 

positive  pole           ....•••••  275 

196.  Method  of  connecting  coil  to  tube.     Valve  tube  on  negative  pole      .            .  275 

197.  Tube  stand  for  deep  therapeutic  work     ......  275 

198.  A  convenient  arrangement  of  apparatus  for  therapeutic  work            .            .  276 

199.  Apparatus  arranged  on  an  upright  cabinet          .....  277 

200.  Diagram  to  show  arrangement  of  apparatus  on  an  upright  cabinet  .            .  277 

201.  Complete  Kienbock  quantimeter    ....•••  282 

202.  Arrangement  of  apparatus  and  paper  when  using  Kienbock's  method  of 

estimating  dosage              ......-•  283 

203.  Developing  the  strips           ........  284 

204.  Comparing  the  wet  strip  with  the  standard  scale,  using  the  slide      .            .  285 

205.  Comparison  of  the  dry  strip  without  the  slide    .....  285 

206.  Plain  strips,  exposed  and  developed         .            .            .            .            .            .  286 

207.  Strips  exposed  with  1  mm.  aluminium  and  developed  ....  286 

208.  Strips  exposed  with  aluminium  ladder  and  developed  ....  286 

209.  Chart  of  X-ray  exposures,  to  show  method  used  in  recording  dosage  of 

KienbSck's  method           ........  287 

210.  Lovibond'g  tintometer,  adapted  and  standardised         ....  288 

211.  Curves  showing  colour  developed  by  Sabouraud's  pastille  when  exposed  to 

unfiltered  X-rays  in  measured  doses     ......  290 

212.  Hampson  radiometer            ........  291 

213    Diagram  to  illustrate  a  method  of  circulating  water  to  the  anti-cathode  of  a 

tube 294 

214.  Macalaster  Wiggin  X-ray  tube       .......  295 

215.  Penetrans  tube          .........  295 

216.  Dessauer  therapeutic  tube  ........  296 

217.  Diagram  illustrating  Dr.  Adamson's  method       .....  302 

218.  Diagram  showing  centres  of  areas  to  be  rayed   .....  302 

219.  Chronic  ulcer  of  hand  of  several  years'    duration  showing  improvement 

under  X-ray  treatment    .            .            .            .            .            .            ■            •  306 

220.  Special  form  of  gold  leaf  electroscope       ......  332 

221.  Apparatus  for  pumping  off  and  collecting  radium  emanation              .            .  333 

222.  Combined  pump  and  apparatus  for  concentration  of  radium  emanation  by 

liquid  air     .            .            .            .            •            •            •            •            •            •  333 

223.  Apparatus  for  charging  glass  or  other  applicators  with  radium  emanation  after 

sparkhng     ......••••  334 

224.  Curve  showing  decay  of  radium  emanation  with  time  ....  335 

225.  Arrangement  for  the  preparation  of  water  impregnated  with  radium  emanation  338 

226.  Various  forms  of  radium  applicators         .            .            .            .            •            •  340 

227.  Friction  device  for  charging  electroscopes            .....  342 

228.  Apparatus  for  inhalation  of  radium  emanation  and  oxygen     .            .            .  347 


LIST  OF  ILLUSTRATIONS  xxi 

FlO.  I-AGR 

229.  Glass  applicators  for  employment  of  radium  emanation  .  .  .     348 

230.  Outer  and  inner  tubes  for  salts  of  radium  .....     3.50 

231.  Flat  metal  applicator  .  .  .  .  .  .  .  .351 

232.  Showing  method  of  arranging  tubes  with  filters  .  .  .  .351 

233.  Silver  screen  to  contain  two  tubes  .  .  .  .  .  .351 

234.  Radium  in  a  flat  metal  tube  showing,  by  dotted  Lines,  area  of  active  service.     351 

235.  Radium  tube  contained  in  rubber  tubing  .  .  .  .  .351 

236.  Radiogene       ..........     357 

237.  Application  of  radium  to  the  eyelid  ......     359 

238.  Circular  applicator  suitable  for  the  treatment  of  superficial  skin  lesions       .     361 

239.  AppUcator  in  box      .  .  .  .  .  .  .  .  .361 

240.  Uterine  sound  with  radium  tube  at  extremity    .....     366 

241.  Radium  tube  arranged  for  the  treatment  of  the  floor  of  the  mouth  .  .     373 

242.  Radium  tube  in  an  oesophageal  tube,  arranged  for  the  treatment  of  an 

oesophageal  growth  ........     374 

243.  Tube  arranged  on  a  length  of  pliable  silver  wire  ....     374 

244.  Shows  radium  tube  in  situ,  for  the  treatment  of  carcinoma  of  the  oesophagus, 

situated  close  to  the  cricoid  cartilage    ......     375 

245.  Diagram  to  illustrate  method  of  introducing  radium  tubes  into  lower  bowel     376 


PAET  L-EADIOGKAPHY 


SOURCES  OF  ELECTRIC    ENERGY 
Continuous  Current  Supply 

The  most  efficient  and  the  most  convenient  form  of  electric  supply  is 
the  continuous  current,  because  it  can  be  used  without  any  alteration  or 
modification  for  all  types  of  interrupters.  For  mercury  interrupters  provi- 
sion should  be  made  for  a  current  supply  of  up  to  12,  for  electrolytic  inter- 
rupters up  to  20  amperes  or  more.  These  currents  \vill  suffice  for  an  ordinary 
installation  where  very  rapid  exposures  are  not  necessary.  When  wiring 
for  an  installation  it  is  always  advisable  to  have  installed  wires  of  larger 
capacity  than  the  actually  required  amperage,  for  we  may  at  a  later  date 
require  a  larger  current  for  a  more  powerful  outfit,  which,  to  operate  to  its 
full  output,  may  require  up  to  50  amperes.  The  tendency  is  to  increase 
the  current-consuming  capacity  of  the  apparatus — single-flash  coils,  Snook 
apparatus,  and  modern  high  -  tension  transformers  requiring  for  an 
instantaneous  exposure  from  60  to  80  amperes. 

When  arranging  for  a  current  supply  for  one  of  these  outfits  it  is  well 
to  provide  for  100  ampere-circuit,  in  order  that  the  operator  need  have  no 
fear  of  either  overloading  his  main  cables  or  blowing  his  main  fuses. 

The  main  fuses  of  such  installations  should  be  in  an  accessible  position, 
and  it  is  well  to  have  a  supply  of  fuse  wire  near  at  hand,  and  when  large  fuse 
cartridges  are  used  a  spare  one  should  always  be  kept  ready  for  use.  Much 
annoyance  from  delay  may  thus  be  avoided.  It  is  of  the  greatest  practical 
value  to  have,  instead  of  the  ordinary  wall  plug,  a  double-pole  switch  and 
two  single-pole  cut-outs  enclosed  in  a  lock-up  case  fitted  on  the  wall  of  the 
radiographic  room.  In  this  way  the  switch  and  fuses  are  always  accessible, 
and  in  addition  it  is  possible  by  opening  the  switch  to  isolate  all  the 
apparatus  from  the  supply  mains. 

Alternating  Current  Supply 

If  the  supply  is  an  alternating  current  with  a  periodicity  of  40  to  60, 
and  the  X-rays  are  not  needed  for  very  short  exposures,  it  may  be  coupled 
directly  to  some  types  of  mechanical  interrupters.  One  of  the  most  useful 
types  of  installation  for  alternating  current  is  a  Gaiffe  Rochefort  transformer 
with  a  Gaiffe  gas  mercury  interrupter.     Very  good  work  may  be  done  with 


EADIOGEAPHY 


this  apparatus,  and  the  only  difficulty  occurs  in  the  starting  of  the  interrupter ; 

the  motor  has  to  synchronise  with  the 
periodicity  of  the  supply,  and  it  requires 
a  httle  practice  to  enable  the  operator 
to  overcome  this  initial  difficulty. 


Apparatus  for  Heavy  Discharges 

When  it  is  necessary  to  use  heavy  cur- 
rents for  instantaneous  radiography  then 
a  high-tension  rectifier  or  a  powerful  coil 
outfit  is  necessary.  Such  a  form  is  illus- 
trated in  Fig.  2.  These  high-tension  rectifiers 
are  designed  for  generating  absolutely 
contiauous  current  impulses  for  the  tubes 
and  for  producing  large  outputs  for  rapid 
and  instantaneous  radiography,  in  order 
to  secure  good  radiographs  and  screen 
pictures  without  at  the  same  time  pro- 
ducing any  inverse  radiation. 

The  principle  of  such  an  apparatus  is 
as  follows  :  Alternating  current  is  stepped 
up  by  means  of  a  high-tension  transformer 
to  the  pressure  necessary  to  stimulate  an 
X-ray  tube,  but  as  continuous  current 
is  necessary,  the  high-tension  alternating 
current  is  converted  into  a  pulsating  con- 
tinuous current  by  means  of  a  synchronous 
rectifier. 

The  chief  factor  is  therefore  a  high- 
tension  rectifier  which  is  designed  on  the 
principle  of  the  well-known  commutator 
employed  for  dynamos  and  motors.    This 

Fig.  1.— GaiflTe  Rochefort  outfit  for  alterna-    rectifier  is  COUpled  mechanically  and  elec- 
ting or  continuouscurrent.  For  alternating  trically  with  the  motor,  alternating  in  such 

supply  there  is  a  dmerence  m  the  arrange-  "  . 

ment    of   the    interrupter.      (Medical  a  manner  that  Commutation  takes  place 
Supply  Association.)  -^  synchronism  with  the  frequency  of  the 

alternating  current.  For  instance,  if  alternating  current  is  available  having 
a  frequency  of  50  cycles  per  second,  the  rectifier  will  give,  in  the  same 
time,  one  hundred  continuous  current  impulses,  or  expressed  scientffically, 
the  rectifier  is  in  synchronism  with  the  alternating  current. 

The  commutation  of  the  rectifier  always  occurs  at  the  moment  when  the 
alternating  current  is  at  zero  value,  that  is,  at  the  moment  of  the  change  of 
direction.  When  working  accurately  this  arrangement  practically  prevents 
the  generation  of  inverse  current  which  is  so  harmful  to  the  tubes. 


SINGLE  IMPULSE  APPARATUS 


Synchronism  is  obtained  simply  and  absolutely  by  employing  a  rotary 
converter  which  is  connected  to  a  continuous  supply,  and  which  at  the  same 
time  supplies  the  alternating  current 
to  the  transformer  and  rotates  the 
rectifier  which  is  mounted  on  the  same 
shaft. 

Alternating-  Current  High- 
tension  Rectifier. — When  using  the 
alternating  current,  the  current  for  the 
transformer  is  derived  direct  from  the 
supply,  the  rectifier  being  driven  by  a 
self-starting  single-phase  synchronous 
motor  which  takes  the  place  of  the  con- 
verter. 

The  outfits  made  for  alternating 
current  are  smaller  than  for  continuous, 
and  these  small  outfits  are  without 
doubt  the  best  to  use  where  ordinary 
X-ray  work  only  is  required,  that  is  not 
instantaneous,  as  there  is  no  trouble 
from  inverse  radiation,  no  interrupter 
to  synchronise,  no  rectifier  to  attend 
to,  and  no  expensive  rotary  converter  required. 


Fig.  2. — Alternating  current  LiKn-tcii-iou 
rectifier.     (Siemens.) 


Apparatus  for  the  Production  of  Single-Impulse 
Radiographs 

The  rapid  development  of  the  finer  methods  of  examination  by  means  of 
X-rays  has  set  the  designers  of  electro-medical  apparatus  a  number  of  new 
problems.  It  was  necessary  to  increase  the  capacity  of  the  X-ray  apparatus 
in  order  to  meet  the  demands  of  medical  science,  particularly  of  that  branch 
devoted  to  the  internal  organs.  It  was  necessary  to  evolve  new  apparatus,  not 
only  capable  of  meeting  the  requirements  of  the  ordinary  X-ray  practice,  such 
as  therapeutic  irradiation,  the  ordinary  X-ray  illumination,  and  the  produc- 
tion of  time  and  instantaneous  exposures,  but  also  sufficiently  powerful 
to  give  sharp  photographs  of  organs  in  motion,  such  as  the  stomach  and 
heart. 

While  in  the  case  of  the  stomach  with  its  comparatively  slow  movements 
an  exposure  from  l  to  J^-  second  is  sufficient  to  give  sharp  pictures,  in  the 
case  of  the  heart  the  exposure  must  only  be  about  -^^0  second  in  order  to 
produce  a  sufficiently  sharp  silhouette  of  the  heart  on  the  photographic  plate. 
The  lungs,  and  especially  the  glands  and  vessels  at  the  hilus,  also  show  up 
well  in  these  instantaneous  photographs,  which  have  been  termed  "  single- 
impulse  photographs,"  so  that  the  smallest  infiltrations,  which  would  not 
be  easily  seen  with  longer  exposures  on  account  of  the  action  of  the  heart. 


6  KADIOGRAPHY 

can  easily  be  diagnosed  by  the  observer.  Further,  the  act  of  swallowing 
can  be  very  well  studied  by  the  single-impulse  method. 

Attempts  have  frequently  been  made  to  solve  the  problem  of  taking 
X-ray  photographs  with  exposures  of  about  j^ho  second,  and  the  apparatus 
constructed  for  this  purpose  was  chiefly  based  on  a  single  sudden  interruption 
of  the  primary  current  of  the  induction  coil,  so  as  to  obtain  a  very  powerful 
inductive  current  in  the  secondary,  sufficient  to  produce  a  brilliant  lighting 
up  of  the  X-ray  tube. 

It  is  obAdous  that  this  single  short-current  impulse  through  the  X-ray 
tube  must  be  of  great  intensity.  This  implies  induction  coils  of  particularly 
powerful  construction  dif!ering  considerably  in  electrical  and  magnetic 
respects  from  the  customary  intense  current  induction  coils  used  up  to  the 
present  for  the  pseudo-instantaneous  exposures.  These  induction  coils  are 
recognised  externally  by  being  provided  with  a  heavy  and  substantial  iron 
core. 

In  spite  of  the  heavy  currents  in  the  primary  circuit — currents  closely 
approaching  the  maximum  permissible  in  the  usual  supply  mains — it 
was  not  found  possible  to  secure  radiographs  of  sufficient  clearness  in  all 
cases,  for  instance  in  the  stomach  of  stout  people  or  distant  exposures 
of  the  thorax.  In  such  cases  recourse  had  to  be  had  to  the  customary 
methods  of  instantaneous  radiography,  i.e.  the  use  of  induction  coils  working 
with  a  mercury  or  Welmelt  interrupter.  For  this  method  of  working,  how- 
ever, the  single-impulse  induction  coil,  which  is  very  sluggish  magnetically, 
is  not  very  suitable,  i.e.  the  times  of  exposure  required  when  using  inter- 
rupters were  relatively  longer  than  those  required  for  the  smaller  intense- 
current  induction  coils,  quite  apart  from  the  fact  that  the  short- 
time  exposures  {^^  second  to  -1-  second)  which  might  be  obtained  with 
the  high-voltage  rectifier  were  not  nearly  approached.  An  improved 
apparatus  has  been  constructed.  This  equipment  is  a  combination  of  the 
well-known  high-tension  rectifier  with  a  single-impulse  apparatus.  It 
enables  radiographs  of  the  heart  to  be  taken  with  exposures  of  about  y^-Q 
second  by  the  single-impulse  method,  and  permits  all  other  radiographs 
to  be  taken  by  means  of  the  rectifier  with  exposures  up  to  -^^  second. 

There  are  other  advantages  connected  with  the  use  of  this  form  of 
apparatus,  in  addition  to  the  considerably  reduced  exposures,  which  are 
impossible  with  the  single-impulse  induction  coil  outfit  when  working  with 
interrupters. 

It  is  of  great  advantage  that  the  transformer  which  is  used  in  the 
customary  manner  for  working  with  the  rectifier  is  also  used  for  the  photo- 
graphs on  the  single-impulse  method.  As  compared  with  induction  coils 
with  open  magnetic  circuit,  the  transformer  with  its  closed  iron  core  possesses 
a  much  higher  efficiency.  This  is  of  particular  advantage  in  connection  with 
the  single-impulse  method,  as  the  current  taken  from  the  power  mains  may 
be  kept  within  the  prescribed  limits,  a  matter  of  considerable  importance. 

In  this  connection  the  further  advantage  may  be  pointed  out  that  the 
equipment  can  be  connected  directly  to  400- volt  power  circuits  ;  this  voltage 


APPARATUS  FOR  SINGLE-IMPULSE  AND  RAPID  RADIOGRAPHY  7 

is  now  frequently  adopted,  but  is  unsuitable  for  induction  coils,  and  a  reduc- 
tion in  the  voltage,  which  is  in  most  cases  not  feasible,  would  be  necessary 
for  satisfactory  operation. 

A  description  of  the  single-impulse  system  is  as  follows  :  Using  the 
apparatus  as  a  rectifier  the  continuous  current  is  converted  into  alternating 


Fig.  3. — Single  impulse  outtit  (Siemens),  showing  switch  (2),  and  switch-table  with  time  relay  (4) 
for  using  outfit  as  a  rotating  high-tension  rectifier.  Cabinet  (3)  contains  single-impulse 
transformer  and  rectifier,  connected  to  au  X-Ray  tube  (1). 

current  by  means  of  a  rotating  converter,  the  alternating  current  being  fed 
to  a  high- voltage  transformer. 

The  alternating  current  from  the  transformer  is  led  through  the  rectifier 
driven  by  the  rotary  converter,  the  high-tension  alternating  current  being 
thus  converted  into  high-tension  continuous  current.  This  high- voltage 
continuous  current  is  measured  by  a  milliamperemeter  and  then  led  through 
the  X-ray  tube. 

The  current  in  the  tube  is  adjusted  by  resistances  which  are  so  pro- 


8  KADIOGRAPHY 

portioned  that  the  current  may  be  adjusted  from  |  milliampere  to  about 
80  milliamperes. 

For  taking  single-impulse  photographs  the  rotary  rectifier  is  no  longer 
used,  but  only  the  high-voltage  transformer  built  into  the  apparatus.  For 
single-impulse  operation  the  transformer  is  no  longer  excited  by  the  alternat- 
ing current  from  the  converter,  but  obtains  its  current  through  the  single- 
impulse  switch  from  the  continuous  current  mains. 

The  principle  of  the  single-impulse  method  is  briefly  as  follows :  In 
the  methods  known  hitherto,  the  current  flowing  through  the  primary  winding 
of  the  induction  coil  is  suddenly  interrupted  after  reaching  its  maximum 
intensity,  i.e.  at  the  moment  when  the  iron  core  of  the  induction  coil  has 
attained  maximum  saturation,  and  the  result  of  the  sudden  disappearance  of 
the  flux  is  an  inductive  "  kick  "  in  the  secondary  winding.  The  force  of  this 
inductive  "  kick  "  is  considerably  greater  in  this  method  inasmuch  as  the 
flux  in  the  iron  core  does  not  merely  drop  from  its  maximum  to  zero  but 
from  a  positive  to  a  negative  maximum.  In  consequence,  the  induction 
in  the  secondary  winding  must  be  particularly  strong,  and  the  X-ray  tube 
gives  a  flash  of  more  than  double  the  intensity  that  would  be  obtained 
with  a  simple  interruption  of  the  current.  Measurements  have  shown 
that  the  time  of  exposure  with  this  method  is  j^  second.  This  increase 
in  efiect  is  obtained  by  reversing  the  primary  current.  The  whole  of  the 
switch  operation  is  carried  out  by  simple  manipulation  of  a  hand-wheel 
at  the  single-impulse  switch-table.  After  taking  a  single-impulse  photo- 
graph, the  smtch  is  immediately  ready  for  use  again,  so  that  an  unlimited 
number  of  single-impulse  photographs  can  be  taken  in  succession  without 
any  parts  requiring  to  be  changed  or  reset.  The  intensity  of  the  various 
impulses  can  be  varied  within  wide  limits  by  a  regulating  resistance. 

It  is  obvious  that  the  X-ray  tube  is  subjected  to  much  more  severe 
treatment  than  in  the  case  of  the  other  methods  hitherto  used.  In  develop- 
ing the  single-impulse  equipment,  the  problem  of  making  an  X-ray  tube 
capable  of  withstanding  these  heavy  current  impulses  had  to  be  solved. 

The  X-ray  tubes  in  general  use  at  that  date  were  more  or  less  useless. 
Even  the  tubes  with  thickened  platinum  anti-cathode  cannot  stand  more 
than  a  few  flashes  with  the  single-impulse  equipment ;  either  the  platinum 
mirror  is  destroyed  or  the  tube  shows  signs  of  being  burnt  in  places.  The 
latter  causes  blurred  photographs,  thus  partly  counterbalancing  the  ad- 
vantages of  the  single-impulse  method  wth  its  sharp  heart  radiographs. 
A  sharp  focus  must,  therefore,  be  insisted  on. 

It  was  found  that  the  metal  tungsten  is  a  very  suitable  material  for 
anti-cathodes  as  it  has  a  higher  melting-point  than  platinum  and  is  a  good 
conductor  of  heat,  so  that  tubes  in  which  this  metal  is  employed  are  capable 
of  withstanding  the  severe  treatment  to  which  they  are  subjected  on  the 
single-impulse  method,  and  it  was  further  found  that  these  tubes  can  be 
provided  with  a  sharp  focus.  Further,  as  a  thick  block  of  tungsten  can  be 
used  as  anti-cathode,  such  tungsten  tubes  have  an  almost  unlimited  life, 
whilst  platinum  tubes  are  destroyed  after  several  flashes. 


APPARATUS  FOR  TIME  AND  RAPID  RADIOGRAPHY 


It  was  also  observed  that  ifi  consequence  of  the  advantages  mentioned 
above,  the  tungsten  tubes  give  photographs  which  are  richer  in  contrast 
and  deeper  than  those  obtained  with  tubes  with  platinum  cathode. 

The  Snook  apparatus  was  the  first  interrupter] ess  machine  made  in 
a  practical  form  for  X-ray  work,  and  was  first  introduced  and  made  in  Eng- 
land in  1907,  the  credit  of  the  design  being  entirely  due  to  Mr.  H.  Clyde 
Snook  of  Philadelphia. 

The  machine  consists  essentially  of  three  parts  :  the  motor  converter, 
the  high-tension  transformer,  and  the  high-tension  rectifier  or  commu- 


•Snook  apparatus.     (Newton  and  Wright.) 


tator.  In  the  case  of  the  machine  designed  to  run  on  continuous  current, 
the  part  first  named  consists  of  a  motor  usually  about  4  k.w.  in  size,  which  runs 
from  the  main  at  about  1500  revolutions  per  minute.  This  machine  has  a 
pair  of  so-called  shp  rings,  from  which  can  be  obtained  an  alternating  current. 

This  alternating  current  is  connected  to  the  primary  circuit  of  the 
transformer,  through  a  controlhng  rheostat,  and  is  raised  in  electrical  pressure 
or  voltage  to  the  necessary  tension  for  X-ray  work. 

This  high-tension  current  is,  however,  alternating  in  character,  whereas 
for  the  production  of  X-rays  it  is  necessary  to  have  a  discharge  in  one  direc- 
tion only,  and  the  latter  is  obtained  by  means  of  the  high-tension  rectifier. 


10 


EADIOGEAPHY 


This  consists  of  a  number  of  ebonite  tubes,  through  which  conductors 
pass,  mounted  on  an  axis,  and  rotated  by  the  motor  converter. 

In  revolving  the  conductors,  connect  the  current  from  the  secondary 
or  high-tension  side  of  the  transformer  to  the  spark-gap,  to  which  the  X-ray 
tube  is  finally  connected,  and  also  reverse  the  direction  of  the  part  of  the 
alternating  current,  which  would  otherwise  pass  through  the  tube  in  the 
wrong  direction. 

The  great  feature  of  the  machine  is  that  this  rectifier  is  carried  on  the 
shaft  of  the  motor  which  is  generating  the  initial  alternating  current  by 
virtue  of  its  rotation,  and  therefore  the  machine  cannot  get  what  is  called 
"  out  of  phase." 

The  general  arrangement  of  the  different  parts  is  shown  in  the  diagram 
below,  and  the  whole  mechanism  is  entirely  enclosed  in  a  cabinet  o£  polished 
woodwork  to  deaden  the  otherwise  disagreeable  noise  of  the  apparatus  when 
in  action. 

If  an  alternating  current  is  available,  the  motor  converter  is  replaced 
by  a  small  synchronous  motor  for  rotating  the  rectifier,  the  main  current 

being    used    in   the    trans- 
former direct. 

In  this  case  the  syn- 
chronous motor  must  be  very 
carefully  designed  and  con- 
structed, otherwise  it  will 
cause  trouble  if  there  is  any 
possibility  of  its  running 
other  than  absolutely  in 
step  or  synchronism  with 
the  current. 

The  apparatus  is  much 

preferred   to    an    induction 

(Newton  and  Wright.)  coil  by  many  workcrs,  owing 

to   the   possibility  which  it 

affords  of  using  very  heavy  currents,  enabling  practically  instantaneous 

radiograms  of  any  part  of  the  body  to  be  taken,  and  also  on  account  of 

the  ease  with  which  the  current  can  be  regulated. 

The  machine,  moreover,  produces  a  perfectly  unidirectional  current, 
entirely  free  from  any  inverse  discharge  in  the  wrong  direction,  which  is  a 
great  advantage  from  the  point  of  view  of  the  life  and  general  working 
condition  of  the  X-ray  tube. 

Accumulators 

If  no  current  from  a  main  is  available,  accumulators  may  be  used 
provided  there  is  an  opportunity  of  getting  them  recharged  easily ;  but  it 
must  be  understood  that  the  time  of  exposure  required  will  be  much 
longer,  because  with  twelve  2 -volt  accumulators  we  cannot  produce  the  same 
intense  discharge  which  can  be  produced  with  a  100-  or  200- volt  supply.     If 


LV      V 


\AA/WVWWW[ 


/^^ 


Fig.  5. — Diagram  of  Snook  apparatus. 


ACCUMULATORS  AND  DYNAMOS 


11 


there  is  no  facility  for  recharging;  the  accumulators,  twelve  or  more  large 
bichromate  cells  may  be  used  ;  but  if  the  apparatus  is  required  for  use  fre- 
quently, the  recharging  of  bichromate  cells  is  troublesome.  In  such  circum- 
stances other  methods  of  obtaining  a  supply  of  current  must  be  adopted, 
such  as  the  use  of  a  3mall  gas  engine  and  dynamo. 


I'Vee  negative  terminal. 


f 


I 


f 


I 


i 


I 


i 


i 


1 


I 


I 


I 


I  Free  positive  terminal. 

Fig.  6. — Accumulator  connections.     The  positive  wire  going  to  the  coil  is  connected  \\p  with  the 
free  positive  terminal  of  the  accumulators  and  the  negative  wire  with  the  free  negative  terminal. 

A  practical  point  of  some  importance  in  the  use  of  accumulators  is  to 
see  that  they  are  kept  well  charged  and  ready  for  use.  It  is  also  well  to 
remember  the  mode  of  connection  to  the  coil  and  break.  The  drawing  above 
illustrates  this  point. 

Dynamos 

A  gas  or  oil  engine  can  be  used  to  drive  a  small  dynamo.     The  oil  motors 


Fig.  7. — Gas  Engine  and  Dynamo.     Generator  set  with  petrol  engine.     (Siemens.) 

are  similar  to  those  used  in  automobiles  ;    they  can  be  easily  started,  are 
small  and  portable. 


12  KADIOGEAPHY 

It  is  hardly  necessary  to  go  into  details  of  these  outfits  as  the  occasion 
for  their  use  is  rarely  likely  to  occur  except  in  remote  country  districts,  or 
for  military  purposes. 

Motor  Transformers 

These  transform  the  alternating  current  into  a  continuous  one,  a  motor 
driven  by  an  alternating  current  being  coupled  to  a  dynamo  which  delivers 
a  continuous  current.  The  size  ought  to  be  chosen  so  that  at  least  1000  to 
2000  watts  can  be  obtained  from  the  dynamo.  These  motor  transformers 
are  very  reliable,  easy  to  work,  and  require  scarcely  any  attention.  The 
motor  transformer  should  be  placed  on  a  solid  bed-plate  and  well  away 
from  the  X-ray  room,  as  the  noise  they  make  is  a  constant  source  of  annoy- 
ance to  the  operator. 

Having  briefly  considered  the  sources  of  electric  current  the  next  step 
is  to  follow  the  process  of  utilising  the  current  we  have  at  hand,  which  is 
a  low-tension  one,  and  useless  for  the  stimulation  of  an  X-ray  tube.  Owing 
to  the  high  resistance  of  such  a  tube,  the  100-  to  250- volt  currents  supplied 
on  most  mains  cannot  find  a  path  through  it. 

The  construction  of  the  X-ray  bulb  is  such  that  the  current  has  to 
overcome  a  very  high  resistance  between  the  two  terminals,  and  it  is  necessary 
to  have  a  high  tension  of  100,000  volts  to  do  this.  The  low-tension  current 
can,  however,  be  converted  into  a  high-tension  one  by  transformation.  A 
low-tension  current  of  100  volts  may  readily  be  changed  into  one  of  100,000 
by  means  of  such  a  transformer. 

The  transformers  most  generally  used  are  induction  coils,  and  these  will 
be  considered  first,  though  the  tendency  is  increasing  to  use  high-tension 
rectifiers  for  the  production  of  powerful  currents.  These  will  be  considered 
later.  The  necessary  current  may  also  be  produced  by  means  of  the  static 
machine.  A  large  Wimshurst  or  Holz  machine  will  produce  enough  current 
to  work  an  X-ray  tube. 

The  Induction  Coil 

The  primary  coil  may  be  divided  into  various  windings  in  order  to  change 
the  self-induction.  These  are  connected  up  to  terminals  at  one  end  of  the 
coil  and  vary  the  quantity  of  current  in  the  primary.  They  may  be  wired 
up  to  a  switch-table  and  controlled  from  there,  so  that  the  operator  may 
select  the  winding  most  suitable  for  the  work  required. 

This  arrangement,  combined  with  a  triple  Wehnelt  electrolytic  in- 
terrupter, enables  us  to  have  a  wide  range  of  action  to  select  from. 

The  essential  parts  of  an  induction  coil  are  : 

(a)  A  primary  coil  consisting  of  a  number  of  thin  sheets  of  metal  or  wire 
of  a  special  magnetic  iron  round  which  a  number  of  turns  of  thick  copper 
wire  are  wound.  This  is  placed  in  an  ebonite  tube  to  insulate  it  from  the 
secondary  coil.     The  thin  sheets  should  also  be  insulated  from  each  other. 

(6)  The  secondary  coil  consists  of  many  thousand  turns  of  thin  copper 


THE  INDUCTION  COIL 


13 


wire  wound  in  a  number  of  tli'in  vertical  sections.  A  diagrammatic  repre- 
sentation will  best  show  the  connections  of  the  primary,  secondary,  con- 
denser, and  interrupter  of  an  induction  coil. 


Fig.  8. — Induction  coil.     (Newtou  and  Wright.) 

T  (Fig.  9)  represents  the  iron  core,  P  the  primary  or  thick  copper 
winding,  P  and  T  together  forming  the  electro-magnet. 

SS  is  the  thin  or  secondary  winding,  which  in  nearly  all  modern  large 
coils  is  now  wound  in  a  number  of  separate  flat  sections  from  end  to  end, 
each  section  insulated  from  the  next  by  a  partition  of  some  insulating 
material,  the  sections  being  joined  together  alternately  by  their  inner  and 


Fig.  9. — Flan  of  -winding  of  coil,  primary,  secondary,  and  connection 
to  condenser  and  break. 

outer  windings,  so  as  to  form  one  continuous  helix  the  whole  length  of 
the  coil. 

Between  the  secondary  SS  and  the  primary  winding  PP  is  the  insulating 
or  primary  tube,  not  shown  in  the  diagram. 

B  represents  the  simplest  pattern  of  contact  breaker. 

H  is  a  piece  of  soft  iron  carried  on  a  stifi  brass  spring,  which  is  pulled 
towards  the  magnet  T  whenever  the  latter  is  magnetised. 

B  is  a  pair  of  platinum-tipped  contacts,  the  front  piece  attached  to 
the  brass  spring  and  iron  pole  piece  H,  the  back  one  brazed  to  an  adjoining 
screw  d,  working  in  a  collar  h,  so  that  the  distance  between  the  platinum 
tips  can  readily  be  adjusted. 

The  current  is  passed  from  the  positive  pole  of  battery  or  mains  into 


14  RADIOGRAPHY 

the  adjusting  screw  d,  thence  through  the  platinum  contacts  B,  the  primary 
winding  PP,  thence  back  to  the  negative  pole  Tg.  The  circuit  being  com- 
pleted, the  core  T  becomes  magnetised,  the  iron  hammer  H  is  attracted, 
and  the  platinum  contacts  are  pulled  apart,  thus  breaking  the  circuit. 

The  core  thereby  becoming  demagnetised,  the  platinum  contacts  are 
pulled  together  again  by  means  of  the  brass  spring,  and  contact  is  again 
made,  and  the  core  T  again  magnetised,  and  so  on.  C  is  the  condenser, 
the  thin  lines  representing  leaves  of  tin-foil,  the  thick  ones  insulating  partitions 
of  waxed  or  varnished  paper. 

When  the  contact  at  B  is  broken,  the  current  passes  into  one  side  of  the 
condenser  at  C,  and  by  providing  this  alternative  path  the  necessary  sparking 
at  B  is  greatly  reduced,  and,  what  is  of  much  greater  consequence,  the  sudden- 
ness of  the  break,  and  therefore  the  speed  at  which  the  core  becomes  de- 
magnetised, is  greatly  increased. 

A  brief  consideration  of  the  construction  and  uses  of  a  condenser  will 
help  to  enable  us  to  understand  its  action. 

The  condenser  consists  of  a  number  of  sheets  of  tin-foil  which  are  in- 
sulated from  one  another  by  sheets  of  waxed  paper,  the  condenser  being 
usually  enclosed  in  the  base  of  the  coil.  The  author  usually  insists  on  having 
two  condensers  connected  to  each  coil  in  order  to  avoid  delay,  as  should 
one  become  pierced,  the  other  can  quickly  be  connected  up  and  work  go 
on  at  once.  This  is  rather  an  important  point  when  a  considerable  amount 
of  work  has  to  be  done. 

The  condensers  should  be  placed  in  an  easily  accessible  position  to  avoid 
delay  in  changing  when  one  goes  out  of  order. 

The  electric  motive  force  or  spark  leng-th  increases  with  the  number 
of  turns  of  the  secondary  winding. 

By  choosing  the  number  of  turns  it  is  possible  to  transform  a  primary 
current  of  200  volts  to  50,000  or  100,000,  but  the  number  of  amperes  is 
reduced  in  the  same  proportion  because,  though  the  numbers  of  the  volts 
and  amperes  can  be  changed  by  transformation,  the  total  energy  can  never 
be  increased. 

If  the  transformation  could  be  effected  without  loss,  a  current  of  say 
200  volts  and  10  amperes  could  be  transformed  into  50,000  and  40  milli- 
amperes,  but  as  losses  occur  in  every  transformation  of  energy  by  friction, 
radiation,  and  conversion  into  heat,  the  current  obtained  under  the  above 
conditions  will  be  between  25  and  30  milliamperes  instead  of  reaching  to 
40  milliamperes. 

To  overcome  the  resistance  of  an  air-gap  of 

4  inches  8  inches  12  inches  16  inches 

110,000  150,000  190,000  230,000  volts 

are  necessary. 

Coils  are  provided  with  sparking  pillars.  One  of  these  has  usually 
a  point,  while  the  other  is  provided  with  a  plate.  This  arrangement  is 
useful  for  the  detection  of  the  polarity.     The  sparks  will  discharge  easily 


CONNECTIONS  OF  X-RAY  TUBE  TO  COIL  15 

from  the  point  to  any  part  of  the  plate  when  the  latter  is  the  negative  pole 
as  shown  in  Fig.  10. 

When  the  point  is  the  negative  pole  the  sparks  will  discharge  from 
the  edge  of  the  plate  to  the  point  as  shown  in  Fig.  11,  because  the  dis- 
charge would  then  be  easier  than  from  point  to  plate. 

Fig.    10. — Connections  of  the  X-Ray  tube  to  Fig.  11. — Connections  of   the  X-Ray  tube  to 

the  coil  (Schall),  showing  tlie  route  travelled  the    coil  (Schall),   showing    the    appearance 

by  the  sparks  when  the  point  is  the  positive  when  the  poles  are  reversed, 
pole  and  the  negative  the  plate. 

When  a  current  is  sent  through  the  primary  winding  the  iron  core 
becomes  magnetised  and  a  magnetic  field  is  created. 

The  appearance  or  disappearance  of  the  field,  or  any  variation  in  its 
intensity,  induces  currents  of  short  duration  in  the  secondary  coil,  their 
intensity  depending  on  the  intensity  of  the  magnetic  field,  and  the  sudden- 
ness of  its  appearance  or  disappearance. 

To  obtain  X-rays  of  sufficient  intensity  for  short  exposures  powerful 
coils  have  to  be  used.  With  such  powerful  discharges  as  are  necessary 
for  present-day  work  in  hospitals  and  private  practice  it  is  much  better  to 
duplicate  installations  in  order  that  the  various  exposures  required  for 
radiography  and  therapeutic  purposes  may  be  independently  obtained  to 
the  best  advantage.  A  coil  outfit  capable  of  giving  instantaneous  exposures 
is  much  too  wasteful  to  use  for  the  smaller  discharges  required  for  thera- 
peutics, and  when  an  attempt  is  made  to  combine  the  component  parts 
of  the  installation  so  as  to  give  these  requirements  from  one  and  the  same 
apparatus,  something  must  be  sacrificed,  and  no  doubt  this  fact  explains 
a  good  deal  of  the  trouble  that  is  experienced  when  using  one  installation 
for  all  purposes.  A  large  outfit  should  be  reserved  for  the  radiographic  work, 
a  less  powerful  one  for  therapeutic  work. 

Importance  of  the  Condenser. — Most  coils  are  fitted  with  a  con- 
denser. This  is  absolutely  necessary  when  the  mercury  interrupter  is  used. 
The  condenser  is  connected  in  parallel  with  the  interrupter,  helping  to  reduce 
the  spark  appearing  in  the  interrupter  on  breaking  the  primary  current  and 
to  demagnetise  the  iron  core  rapidly  ;  it  is  quite  unnecessary  when  using 
electrolytic  interrupters. 

The  Control  Apparatus 

A  switchboard  or  switch-table  of  some  form  is  a  necessity.  This 
consists  of  marble  or  slate  panels  on  which  are  mounted  a  main  switch  to 
turn  the  current  on  and  of!,  and  a  variable  resistance  to  control  the  intensity 
of  the  current. 


16  KADIOGEAPHY 

In  most  cases  the  switchboard  is  provided  with  voltmeter  and  ampere- 
meter to  measure  the  primary  cm-rent,  with  a  switch  and  rheostat  to  control 
the  motor  of  the  interrupter,  a  signal  lamp  to  indicate  whether  they  are 
turned  on  or  oS.,  and  the  necessary  fuses  and  terminals. 

In  more  elaborate  installations  the  switchboard  may  be  provided  with 
a  switch  to  allow  the  use  of  either  a  mercury  or  electrolytic  interrupter, 
and  the  use  of  the  anodes  of  the  latter  separately  or  connected  in  parallel ; 
with  a  switch  to  change  the  self-induction  of  the  primary  coil ;  and  with 
an  automatic  switch  and  time  relay  to  break  the  primary  current  auto- 
matically after  setting  to  a  fixed  time  which  can  be  varied  from  0-05  to  10 
seconds. 

Single-impulse  and  similar  forms  of  apparatus  require  a  special  auto- 
matic switch  for  use  when  giving  the  most  rapid  exposures. 

The  next  point  to  consider  at  length  is  the  question  of  the  use  of  a 
rheostat,  an  instrument  which  enables  us  to  vary  the  current  supply  to  the 
primary  coil. 

Two  forms  of  rheostat  may  be  used,  and  it  will  be  well  to  consider  each 
in  detail,  as  a  clear  knowledge  of  their  use  may  prevent  the  operator  from 
making  mistakes,  the  cause  of  which  he  may  have  difficulty  in  understanding. 

When  using  a  series  rheostat  the  full  voltage  of  the  supply  is  reduced 
to  a  very  small  extent,  whereas  by  means  of  a  shunt  rheostat  the  voltage 
can  be  reduced  and  varied  gradually. 

This  latter  form  has  decided  advantages  if  moderate  or  low  pressures 
are  required,  because  the  variable  voltage  gives  a  better  control  over  the 
discharge.  With  a  shunt  resistance  the  discharge  can  be  varied  in  wide 
Umits,  and  it  can  be  better  adapted  to  medium  and  soft  tubes  than  is 
possible  with  the  series  connection. 

As  the  amount  of  reverse  current  generated  is  in  direct  ratio  to  the 
voltage  used  in  the  primary  coil,  less  reverse  current  is  obtained  with  the 
lower  voltage  available  with  a  shunt  than  with  the  higher  voltage  which  is 
inseparable  from  the  series  connection.  The  tubes  have,  therefore,  a  longer 
life  when  used  with  the  shunt  connection,  which  is  consequently  more 
economical  and  to  be  preferred  for  all  time  exposures  and  for  therapeutic 
purposes,  or  in  other  words  whenever  moderate  or  weak  currents  have  to 
be  used  for  a  comparatively  long  time. 

When  short  exposures  are  necessary  the  efiects  on  the  tubes  must  be  to 
a  large  extent  neglected,  and  the  full  voltage  of  the  mains  used,  so  that  a 
larger  milhamperage  can  be  obtained  in  the  tube  circuit,  and  in  all  such 
cases  the  series  connection  with  httle  or  no  resistance  in  the  circuit  is 
better  than  the  shunt  connection. 

The  objection  to  shunt  rheostats  is  that  they  are  wasteful,  and  more 
expensive,  but  after  all  the  cost  of  electrical  current  is  much  less  than  that 
of  tubes,  which  is  undoubtedly  increased  when  series  rheostats  are  used. 
A  complete  switchboard  should,  therefore,  have  both  methods  of  control. 

It  should  be  noted  that  some  authorities  do  not  agree  entirely  with 
the  statements  of  comparison  between  the  two  forms  of  rheostats.     A  good 


THE  INTERRUPTER 


17 


deal  depends  upon  the  construction  of  the  coil  and  the  interrupter,  and  the 
accuracy  with  which  they  are  adjusted  to  one  another.  Other  factors  may 
also  influence  the  degree  of  inverse  current  produced. 


The  Interrupter 

This  important  part  of  an  X-ray  outfit  requires  a  lengthy  consideration, 
and  it  will  well  repay  the  beginner  to  familiarise  himself  thoroughly  with 
this  part  of  his  installation.  He  must  know  its  construction,  how  to  regulate 
it,  and  above  all  how  to  clean  it  when  necessary.  The  interrupter  serves 
the  purpose  of  closing  and  opening  the  primary  circuit.  The  sharper  the 
opening  of  the  primary  circuit,  the  higher  will  be  the  tension  of  the 
secondary  current  —  the  opening  induction  current  —  and  the  greater 
therefore  is  the  discharge. 

For  practical  purposes  there  are  two  types  of  interrupters  which  require 
description.     These  are  : 

(a)  The  Mercury  Interrupter. 

(6)  The  Electrolytic  Interrupter. 

Of  the  former  there  are  many  varieties,  but  it  will  suffice  to  mention 
a  few  and  give  a  short  de- 
scription    of    each    before 
proceeding    to   the  electro- 
lytic type. 

Probably  the  best  all- 
round  interrupter  of  the 
centrifugal  mercury  type  is 
the  Sanax,  but  this  has  one 
objectionable  feature,  viz. 
the  trouble  of  cleaning  it. 
The  undoubted  advantage 
which  other  forms  of  mer- 
cury interrupters  possess 
over  it  is  the  ease  with 
which  they  may  be  cleaned, 
and  owing  to  the  fact  that 
gas  is  used  in  many  as  the  di- 
electric instead  of  paraffin 
they  require  cleaning  less 
frequently,  and  further  the 

mercury     never     becomes  ^^^'  -'-^- — Diagram  to  illustrate  coustruction  of  a  centrifugal 

mercury  interrupter.     (Siemens. ) 
7n,  Motor, 
c^  and  c'',  Contacts. 
d^  and  cP,  Mercury  jets. 
q,  Mercury. 
s,  Adjustable  contact. 


emulsified.  Practically 
every  maker  manufactures 
an  interrupter  of  this  type, 
and  a  general  description 
will  apply  to  all.  The  prin- 
ciple is  the  same  in  each— a  mercury  jet  rotating  in  a  vessel  with  a  gas 


r,  Funnel  for  di-electric. 

V,  Safety  valve. 

u,  Gas  tap. 

e,  Containing  vessel. 

g,  Closing  valve. 


18 


RADIOGEAPHY 


Motor  Resistance 

AAAAAAA^ 


Current  '    ?" 

supply 


AAAAA/" 


Coil  resistance 
Mark  I. 


Motor  resistance 

MA/WW. 


AA/vAAAAA 

Coil  resistance 
Mark  II. 


Q..     O      Switch  for 

O       Second  Contact 


Coil 
Primary 


Fig.  13. — Plan  of  connections  for  Dreadnought  interrupter. 


THE  DREADNOUGHT  INTERRUPTER 


19 


di-electric.  The  gas  supply  may  be  obtained  direct  from  the  mains  or  a 
large  rubber  bag  may  be  inflated  with  gas  and  attached  to  the  tap  on  the 
interrupter.  Fig.  12  illustrates  the  chief  points  of  a  mercury  interrupter. 
Watson  Dreadnougrht  Interrupter. — This  interrupter  consists  of 
two  parts,  the  interrupter  proper  and  the  motor  for 
driving  same.  The  latter  is  usually  mounted  on  the 
top  of  the  interrupter  and  can  be  removed  by  un- 
screwing a  few  milled  nuts,  and  on  lifting  this  top 
with  the  motor,  one  at  the  same  time  lifts  out 
the  rotating  jet  and  the  fixed  contacts  against 
which  the  mercury  impinges,  so  making  and  break- 
ing contact  two  or  four  times  per  revolution. 
The  required  amount  of  mercury  is  poured  into 
the  vessel  and  the  top  replaced  and  refixed.  The 
interrupter  is  then  connected  to  the  coil  and  con- 
denser and  the  motor  to  the  supply  mains.  Most 
of  these  interrupters  are  provided  with  an  arrange- 
ment of  contacts  and  terminals,  so  that  it  is  pos- 
sible to  double  the  number  of  primary  interruptions,  and  so  increase  the 
efiect  in  the  secondary  or  tube  circuit ;  other  types  have  an  adjustable 
wedge-shaped  contact.  Great  attention  should  be  paid  to  the  cleanHness 
not  only  of  the  interrupter  but  also  of  the  motor,  and  especially  of  the 
commutator  and  oil  cups.  To  fill  the  interrupter  with  gas  one  tap  is 
connected  to  the  gas  supply  by  a  rubber  tube  and  the  other  tap  is  left 


I'iG.  14. — Dreailiiougbt  inter- 
rupter.     (Watson.) 


,^^2k  ^S>t 


Fig.  15. — Dreadnought  interrupter  showing  detail. 


A,  Container. 

B,  Jet. 

C,  Contact  teeth. 
E,  Screw. 


F,    Shaft  bearing. 

H,   Oil  cups. 

K,   Motor  brushes. 


open  for  a  few  moments  in  order  to  expel  the  air.  This  tap  is  then 
closed  and  the  other  connected  to  the  gas  supply  left  open,  and  advantage 
taken  of  the  pressure  from  the  mains.  If  there  is  no  handy  gas  supply  a 
gas  bag  may  be  used  or  ether  vapour.  The  latter  may  be  employed  by 
vaporising  a  small  quantity  of  methylated  ether  placed  on  the  top  of  the 
mercury  and  starting  the  interrupter  with  a  small  current  before  closing 
the  taps. 


20 


EADIOGEAPHY 


Fig.  16. — Instanta  interrupter. 


In  the  Instanta  interrupter  and  others  there  is  an  arrangement  of  four 
jets  so  that  eight  makes  and  breaks  are  obtained  per  revolution,  and  it  is  also 

so  arranged  that  the  circuit  is  broken  in 
two  different  places  at  the  same  moment. 
This  has  the  ef!ect  of  greatly  increasing 
the  suddenness  of  the  interruption. 

Sanax  Interrupter.  —  The  Sanax 
interrupter  consists  of  a  small  steel  pear- 
shaped  bowl  mounted  direct  to  the  axle 
of  an  electric-motor  and  situated  perpen- 
dicularly above  the  motor.  Thus,  when 
the  axle  of  the  motor  rotates,  the  pear- 
shaped  bowl  is  rotated  also.  Inside  the 
bowl  a  very  small  quantity  of  mercury 
(only  10  oz.  weight)  is  placed,  and,  by 
centrifugal  force,  travels  up  the  side  of 
the  bowl  until  it  finds  the  extreme  peri- 
phery, where  a  distinct  groove  or  bed  is 
made  to  receive  it.  Thus  it  will  be  seen 
we  have  a  revolving  bowl  and  in  it  a 
revolving  ring  of  mercury.  Inside  the 
interrupter  bowl  and  carried  on  a  vertical 
spindle  is  a  fibre  disc  with  two  copper 
segments.  This  disc  is  mounted,  free  to  revolve,  on  ball-bearings  top  and 
bottom,  and  is  horizontal  in  position.  It  is  not  placed  in  the  centre  of  the 
bowl,  but  over  to  one  side,  so  that  when  the  bowl  rotates  its  edge  engages 
with  the  rotating  ring  of  mercury  and  is,  therefore,  of 
course,  revolved  by  it.  The  current  is  led  to  the  metal 
bowl  and  to  the  mercury  ring  by  means  of  an  ordinary 
terminal,  and  the  current  is  led  also  to  the  segment  in 
the  disc  by  means  of  the  spindle  carrying  same.  Thus, 
each  time  one  of  the  copper  segments  enters  into  the 
mercury  ring  the  current  is  allowed  to  pass,  and  each 
time  the  segment  leaves  the  mercury  ring  and  the  fibre 
of  the  disc  enters  the  ring,  there  is  an  interruption  period. 
By  the  unique  construction  of  working  two  circles 
together — the  mercury  ring  and  the  fibre  segmented 
disc — a  splitting  up  of  the  mercury,  such  as  would  occur 
by  plunging  into  the  mercury  any  other  form  of  con- 
tact, is  completely  avoided. 

As  already  mentioned,  the  free  revolving  fibre  disc 
with  two  copper  segments  is  placed  not  in  the  centre  of  the  bowl,  but 
eccentrically,  and  can  be  inserted  more  or  less  into  the  mercury  ring  from 
the  outside,  even  if  the  motor  is  running.  This  arrangement  makes  it 
possible  to  put  the  disc  so  that  it  just  touches  the  mercury  ring,  in  which 
case  the  duration  of  contact  is  very  short.     The  further  the  disc  is  put  into 


F:g.  17. 
Sanax  interrupter. 


INTERRUPTERS—CAUSES  OF  DEFECTIVE  WORKING       21 

the  mercury  ring  the  further  the  segment  travels  in  the  mercury,  and 
therefore  the  duration  of  contact  can  be  extended  as  desired.  Moreover, 
the  number  of  interruptions  is  regulated  by  the  speed  of  the  motor  by 
a  special  volt  regulator  mounted  on  the  switchboard,  so  that  not  only  is 
the  duration  of  contact  independent  of  the  number  of  interruptions,  but  both 
are  also  independent  of  the  primary  current. 

The  Di-electric  used  in  the  Sanax  interrupter  is  paraffin.  Alcohol, 
gas,  and  other  di-electrics  have  been  tried,  but  paraffin  has  given  the  best 
results. 

Before  the  introduction  of  the  Sanax  interrupter  the  mercury  inter- 
rupters using  paraffin  as  a  di-electric,  in  spite  of  their  numerous  advantages, 
had  the  great  disadvantage  of  emulsifying  the  mercury.  The  cause  of  this 
is  not  the  burning  of  the  same  by  the  opening  spark  but  the  mechanical 
breaking  up  and  churning  of  it  with  the  di-electric.  After  working  the 
mercury  interrupter  for  a  short  time  it  was  imperative  to  remove  the  dirty 
mercury  and  to  clean  it — a  very  disagreeable  and  troublesome  proceeding. 
The  ingenious  principle  of  the  Sanax  interrupter — the  working  together 
of  the  two  circles  in  unison  and  the  continuous  centrifugal  rotation — delays 
the  emulsification  of  mercury.  In  consequence  of  its  greater  specific  weight 
the  mercury  is  always  driven  to  the  farthest  outside  point  and  disintegrates 
by  itself  all  the  fighter  substances,  therefore  remaining  for  a  longer  or  shorter 
time,  according  to  the  amount  of  usage,  clean  at  the  point  of  interruption. 
The  Number  of  Interncptions  can  be  increased  up  to  about  12,000 
per  minute.  By  means  of  a  turning  switch  on  the  switchboard  the  motor 
can  be  run  fast  or  slow,  and  further,  by  means  of  a  resistance,  it  is  possible 
to  run  the  motor  at  any  desired  speed,  thus  obtaining  any  number  of 
interruptions. 

Causes  of  Defective  Working. — A  few  short  hints  on  the  causes  of  defective 
working  may  be  of  assistance  to  workers.  If  when  switching  on  the  motor  it 
does  not  start  up,  the  speed  regulator  should  be  at  once  cut  out,  and  then  the 
motor  having  started,  it  can  be  brought  back  to  the  position  of  usual  working. 
There  also  may  be  an  interruption  or  short  circuit  in  the  main  cable  leading 
to  the  switchboard  or  table,  or  the  cables  leading  to  the  motor  of  the  inter- 
rupter may  have  become  loosened,  or  the  brushes  and  their  screws  may  have 
become  loose,  all  of  which  faults  would  be  indicated  by  the  motor  refusing 
to  start.  If  the  commutator  starts  to  spark  after  running  some  fcime  it  will 
be  found  that  this  is  generally  due  to  oil  and  carbon  dust,  and  this  must  be 
removed  by  cleaning  the  commutator  with  fine  emery  cloth,  and  also  cleaning 
the  carbon  brushes.  If  when  the  coil  is  now  switched  on  we  observe  no 
fight  in  the  X-ray  tube,  this  may  be  due  to  the  fuse  having  been  burnt 
through  or  become  loosened.  Great  care  must  be  taken  to  see  that  all 
bearing  contacts  are  clean,  that  all  cables  are  perfect,  and  that  all  terminals 
are  absolutely  secure. 

Should  the  tube  give  an  unsteady  fluorescence  this  may  be  due  to  some 
extent  to  the  vacuum  of  the  tube,  and  can  be  controlled  somewhat  by  adjust- 
ing the  interrupter.     If  the  tube  flickers  with  a  contact  of  a  certain  size. 


22 


RADIOGEAPHY 


the  tube  may  be  steadied  by  increasing  this  contact.  This  flickering  may 
be  also  due  to  the  motor  of  the  interrupter  running  slowly.  Another  reason 
for  this  efiect  in  the  tube  may  be  the  piercing  of  the  condenser,  and  this 
can  be  detected  by  testing  the  spark  length  of  the  coil.  If  one  cannot 
obtain  the  full  spark  length  and  the  primary  current  is  above  the  normal, 
then  the  condenser  should  be  carefully  examined.  Finally  the  copper 
contacts  of  all  interrupters  need  replacing  from  time  to  time,  as  they  become 
burnt  through  from  long  usage,  this  leading  to  bad  and  intermittent  working. 

Improved  Mackenzie  Davidson  Interrupter. — This  is  a  useful 
form  of  mercury  interrupter  when  an  outfit  of  moderate  capacity  is  all  that 
is  required,  and  when  accumulators  are  used  as  the  source  of  supply. 

It  consists  of  a  metal  pot  containing  a  supply  of  mercury  into  which 
a  contact  set  at  an  angle  dips.     This  contact  is  mounted  on  the  end  of  the 


Fig.  18.  —  Improved  Mackenzie  Davidson  interrupter.      (Scliall 


shaft  of  a  motor  whose  speed  can  be  varied  in  order  to  vary  the  number 
of  interruptions.  This  interrupter  requires  rather  more  mercury  than  most 
of  the  other  types. 

Electrolytic  Interrupter. — This  type  was  introduced  by  Professor 
Wehnelt.  The  principle  of  construction  is  simple.  A  platinum  wire  and  a 
large  lead  electrode  are  immersed  in  diluted  sulphuric  acid  in  the  proportion 
of  acid  1  oz.  to  5  oz.  of  water. 

This  interrupter  is  without  doubt  a  good  one,  far  exceeding  the  best 
mercury  interrupters,  not  only  in  regard  to  output  and  capacity  for  regula- 
tion, but  also  in  simplicity  of  construction  and  use,  as  well  as  in  safety  of 
working.  Wehnelt  interrupters  can  be  used  wherever  continuous  current 
is  supplied  direct,  i.e.  from  supply  mains,  accumulators  (at  least  about 
65  volts),  or  a  motor  generator,  or  where  single-phase  or  three-phase  current 
is  converted  into  continuous  current  by  means  of   rotary  converters  or 


ELECTROLYTIC  INTERRUPTERS 


23 


electrolytic  valves.     As  all  metals,  with  the  exception  of  platinum,  when 
used  for  the  active  electrode,  even  if  the  polarity  is  correct,  are  rapidly  con- 


^.^S^S 


Fig.   19. — Single-poiut  electrolytic 
interrupter.     (Siemens.) 

a,  Glass  vessel. 

b,  Porcelain  diaphragm. 

c,  Adjustable  ebonite  collar. 

d,  Terminal.  e.  Lead  electrode. 


Fig.  20. — Three-point  electrolytic  interrupter. 
(Siemens. ) 


Fig.    21. — Single-point    electro- 
lytic interrupter.    (Watson.) 

The  upper  part  of  the  inter- 
rupter has  attached  to  it  a 
solenoid  which  is  couuected 
electrically  to  the  switch-table, 
allowing  of  the  control  of  the 
depth  of  point  in  the  fluid. 


Fig.  22. — Trolley  control  table,  with  resistances 
arranged  to  facilitate  time  and  rapid  exposures. 
(Siemens.) 


sumed,  platinum  is  always  used  with  these  interrupters  as  the  active  electrode, 
because  it  disintegrates  very  slowly  and  therefore  gives  the  best  results. 


24 


RADIOGEAPHY 


These  interrupters  are  manufactured  with  1,  2,  3,  4,  or  6  separate  electrodes, 
i.e.  they  are  used  as  single,  double,  triple,  quadruple,  or  sextuple  interrupters. 
When  employing  a  multiple  interrupter  one  is  not  obliged  to  regulate  at  the 
interrupter  itself,  and  can  therefore  set  it  up  outside  the  X-ray  room,  so 
that  its  noise  causes  no  disturbance. 


Fig.  23. — Larger  view  of  top  of  trolley  control  table  to  show  the  regulating  parts.     (Siemens.) 

The  advantages  of  the  Wehnelt  interrupter  are  summarised  briefly  as 
follows  : 

(1)  SimpUcity  of  construction. 

(2)  Convenient  handling  of  the  X-ray  outfit.    The  Wehnelt  interrupter 
requires  no  attention. 

(3)  Largestlcapacity,  as  it  interrupts  very  rapidly  the  largest  amount 
of  energy  and  therefore  the  most  intense  X-rays  are  obtained. 

(4)  Long  life  to  the  tubes  even  when  used  with  heavy  currents. 

(5)  In  comparison  with  all  mechanical  interrupters,  great  reliability. 


METHOD  OF  ACTION  OF  AN  ELECTROLYTIC  INTERRUPTER  25 

This  is  due  to  its  simplicity  of  "construction  and  method  of  working,  the 
absence  of  moving  parts,  and  the  consequent  simplicity  of  connections 
of  the  whole  outfit. 

In  the  case  of  X-ray  outfits  for  rapid  exposures  three  or  more  electrodes 
are  arranged  in  parallel  by  means  of  a  switch,  and  the  electrodes  are  so 
adjusted  that  equal  parts  of  them  interrupt  the  total  current. 

In  conjunction  with  a  time-relay  switch  these  interrupters  can  be  used 
to  obtain  exposures  of  from  -j\y  to  6  seconds  in  connection  with  an  automatic 
cut-out  switch.  Such  a  device  is  illustrated  opposite.  With  the  most  power- 
ful induction  coil  outfit,  such  as  the  single-impulse  apparatus  constructed 
for  use  with  the  electrolytic  interrupter,  a  time-relay  should  always  be 
included,  along  with  a  triple  electrolytic  break,  for  then  we  have  a  large 
range  of  exposures  at  our  command. 

Method  of  Action  of  an  Electrolytic  Interpupter. — AVhen  a 
current  of  at  least  50  volts  and  5  amperes  is  passing  through  the  interrupter 
in  such  a  manner  that  the  platinum  is  the  anode,  the  density  of  the  current 
is  so  great  near  the  small  anode  that  it  becomes  very  hot  and  steam  is 
formed.  In  addition,  electrolysis  causes  hydrogen  and  oxygen  to  appear, 
and  these  gases  form  an  insulating  mantle  round  the  anode  which  inter- 
rupts the  current.  If  there  is  a  sufficient  amount  of  self-induction  m 
the  circuit,  a  spark  appears  at  the  breaking  point,  namely  the  anode, 
ignites  the  gases,  and  the  explosion  gives  the  acid  access  to  the  platinum, 
thus  closing  the  current  again.  This  process  takes  place  with  extraordinary 
rapidity  and  regularity. 

The  intensity  of  the  discharges  and  the  frequency  of  the  interruptions 
can  be  varied  in  the  widest  limits  by  varying  the  electro-motive  force  used 
in  the  primary  circuit,  the  surface  of  the  platinum  anode,  and  the  amount 
of  self-induction. 

The  disadvantage  of  the  electrolytic  interrupter  is  the  great  care  that 
has  to  be  exercised  in  its  use.  Unless  a  considerable  latitude  is  allowed  for, 
the  X-ray  tube  is  more  likely  to  be  damaged,  the  anti-cathode  being  quickly 
pierced  if  too  powerful  currents  are  used  for  long  periods.  When,  however, 
the  electrolytic  interrupter  is  provided  with  three  or  more  points  and  a  suit- 
able switch  on  the  general  or  main  switchboard,  all  degrees  of  exposure  can 
be  successfully  used.  Even  for  therapeutic  work  this  interrupter  when 
properly  used  is  undoubtedly  one  of  the  best  forms  of  interrupter. 

With  a  time-relay  switch  most  powerful  currents  may  be  used  if  only 
for  a  fraction  of  a  second. 

Carelessness  in  leaving  the  thicker  points  in  the  circuit  and  then  using 
it  for  prolonged  screening  will  almost  invariably  ruin  a  tube. 

A  single-point  electrolytic  interrupter  can  be  controlled  from  a  distant 
point  by  means  of  a  solenoid.  In  this  way  it  is  possible  to  vary  the  depth 
of  the  platinum  point  in  the  acid  solution  and  so  vary  the  intensity  of  the 
current  passing  through  the  interrupter.  This  is  a  most  useful  addition 
to  the  electrolytic  interrupter. 

Interrupters   for   Alternating"  Currents.  —  These  are  numerous. 


26 


RADIOGRAPHY 


meclianical  and  chemical,  and  enable  us  to  use  the  alternating  current 
without  rectification. 

Good  though  some  of  these  are,  none  is  so  efl&cient  as  an  interrupter 
on  a  continuous  current  circuit,  and  the  maximum  intensity  which  can  be 
reached  even  with  the  best  alternating  current  interrupter  is  much  less 
than  that  obtainable  with  a  continuous  current. 

When  the  alternating  supply  has  a  higher  periodicity  than  sixty  it  is 
better  to  rectify  the  current  by  installing  a  motor  transformer. 

With  a  periodicity  of  less  than  sixty  the  best  interrupter  to  use  is  that 
made  by  Gaifie  of  Paris.  This  interrupter  and  a  Gaiffe  Rochefort  transformer 
or  coil  may  be  used  for  therapeutic  work  by  utilising  less  of  the  break,  but 


Fig.  24. — Gaiflfe  interrupter. 


V,  Vessel. 

e,  e,  Screws. 

I^,  I^  N,  Terminals. 


M,  Vulcanite  cap. 
B,  Impulse. 
P,  Handle. 


R,  Inlet  tap. 
R\  Outlet  tap. 
C,  Cone. 


b,  b,  Orifices. 

d,  d,  Di,  D2,  Teeth, 


when  required  for  radiography  the  intense  current  is  used.  This  is  done 
by  a  mechanical  contrivance  which  throws  all  the  teeth  in  the  interrupter 
into  action.  Quite  rapid  exposures  may  be  obtained  with  this  apparatus 
especially  if  intensifying  screens  are  used. 

The  mercury  jet  is  caused,  as  in  some  of  the  previous  interrupters,  by  the 
rotation  of  a  cone  with  its  lower  end  in  mercury,  and  by  centrifugal  force 
the  mercury  is  jetted  out  against  the  stationary  contacts.  The  motor  part 
difiers  from  the  continuous  current  interrupter.  The  break  is  started 
with  a  smart  twist  of  the  milled  head  on  top  and  the  needle  of  the  milli- 
ammeter  watched  until  this  is  steady,  this  indicating  that  the  interrupter 
is  in  synchronism  with  the  supply.  Some  operators  can  judge  of  this  by 
sound.  At  first  there  is  a  grating  sound,  and  this  becomes  smooth  when 
synchronism  is  attained. 


ESSENTIALS  FOR  THE  PRODUCTION  OF  X-RAYS  27 

The  essentials  for  the  production  of  X-rays  are  :  (a)  A  supply  of  electric 
energy  ;  (6)  a  means  of  transforming  a  current  of  low  tension  into  one  of 
high  tension  ;   (c)  an  interrupter  ;    (d)  an  X-ray  bulb. 

The  apparatus  employed  may  vary  from  the  simplest  to  the  most 
highly  complicated.  Its  selection  and  arrangement  will  depend  upon  the 
operator  and  the  resources  at  his  command.  Complicated  and  expensive 
apparatus  is  not  absolutely  essential  to  ensure  the  production  of  good  nega- 
tives. The  most  important  point  of  all  is  for  the  operator  to  make  the  most 
of  the  apparatus  at  his  disposal.  When  he  grasps  the  underlying  principles 
of  the  necessary  apparatus,  and  particularly  of  the  technique  of  radiography, 
he  may  venture  to  add  to  his  outfit  those  items  which  are  extremely  useful 
but  not  absolutely  necessary.  A  thorough  understanding  of  the  mechanical 
parts  of  the  installation  is  of  great  value  to  the  radiographer,  but  is  not 
absolutely  necessary,  because  it  is  generally  possible  to  obtain  help  in  the 
manipulation  of  the  apparatus.  But  a  thorough  knowledge  of  the  X-ray 
tube  is  of  the  utmost  importance,  because  it  is  always  the  ruling  factor  in 
radiography  and  therapeutics.  In  order  to  produce  the  best  quaUty  of  X- 
rays  for  a  specific  purpose  in  either  radiography  or  therapeutics  it  is  necessary 
to  have  accessory  apparatus  which  enables  the  operator  not  only  to  control 
the  X-ray  tube  but  to  reproduce  at  will  conditions  which  are  known  to  lead 
to  the  production  of  good  results. 

The  accessory  apparatus  is  therefore  a  most  important  part  of  the 
equipment,  and  must  be  considered  in  detail.  In  the  whole  organisation  of 
an  X-ray  outfit  the  most  important  point  is  to  have  a  good  X-ray  tube  under 
perfect  control,  then  work  becomes  easy  and  good  results  follow. 

In  view  of  the  importance  of  this  subject  the  following  pages  are  devoted 
to  a  fairly  full  account  of  the  manufacture  of  an  X-ray  tube  and  the  apparatus 
necessary  to  enable  the  operator  to  exercise  an  efhcient  control  over  it. 


X-RAY  TUBES  AND  THEIR  ACCESSORIES 


The  Focus  Tube 


This  being  always  the  ruling  factor  in  radiographic  work,  a  complete 
knowledge  of  its  construction  and  method  of  working  is  a  sine  qua  non  in 
the  routine  work.  Should  it  not  be  in  proper  order  the  best  type  of  apparatus 
is  quite  useless  as  a  producer  of  good  radiographs. 

1'he  quality  of  the  focus  tube  is  all  important  for  success  in  X-ray  work, 


Anticathode  Terminal. 


Anticathode  supporting  tube. 

Junction  of  anticathode 
support  and  bulb. 

Anode  Terminal. 


Anode 

Exhaust   Point. 
Glass  Mantle. 
Dark  Hemisphere. 
Anticathode. 
Target 
Regulator  Tube. 

Active  Hemisphere- 
Cathode  Stream. 
Cathode. 


Cathode  stem. 
Regulating  Arm. 

Cathode  Terminal. 


Fig.  25. — Diagram  of  an  X-ray  tube  with  parts  named,  showing  the  paths  of  the  cathode  stream 
from  the  cathode  impinging  on  the  anti-cathode  ;  the  active  hemisphere  shows  the  paths  of 
most  of  the  X-rays  generated.     (Watson). 

as  if  the  tube  is  unsuitable  in  that  it  is  too  hard  or  too  soft,  it  is  impossible 
to  get  good  results. 

If,  on  the  other  hand,  the  tube  is  in  good  order  good  results  may  be 
obtained  with  quite  ordinary  apparatus. 

Tubes  deteriorate  with  use,  but,  carefully  handled,  they  will  outlast 
hundreds  of  exposures,  and  show  very  little  sign  of  damage. 

The  all-essential  point  is  to  know  how  to  use  the  focus  tube,  and  it  is 

28 


DESCRIPTION  OF  MANUFACTURE  OF  THE  X-RAY  TUBE    29 


also  a  great  advantage  to  familiarise  one's  self  with  the  names  of  the  various 
parts. 

Description  of  the  Manufacture  of  an  X-Ray  Tube. — The  first 
process  consists  of  the  blowing  of  a  glass  sphere  of  the  desired  capacity 
with  a  "  neck,"  which  varies  from  one  to  two  inches  diameter,  according  to 
the  size  and  type  of  the  tube.  The  thickness  of  the  walls  of  the  bulb  is 
from  '2  to  "6  mm. 

The  various  metal  parts,  or  electrodes,  having  been  carefully  cleaned, 
are  introduced  through  this  neck,  and  are  in  turn  sealed  into  position  by  the 
glass-blower.  Connections  are  made  to  the  outside  by  fusing  into  the  glass 
pieces  of  platinum  wire,  and  as  each  portion  of  the  tube  is  finished,  it  is 
annealed  with  extraordinary  care.  This  annealing  is  one  of  the  most  im- 
portant processes,  as  an  X-ray  tube  has  to  withstand  the  most  intense  heat. 


Fig.  26. — Radiator  tube  constructed  for  heavy  discharges.     (Cossar. ) 


to  say  nothing  of  the  rough  usage  which  it  may  encounter  if  it  is  destined 
for  a  hospital  career. 

The  electrodes  having  been  placed  in  position,  and  the  regulators,  etc., 
attached,  a  length  of  glass  tubing  is  fused  on,  and  the  tube  is  placed  on  the 
vacuum  pump.  The  final  stages  of  exhaustion  are  sometimes  very  pro- 
longed, varying  according  to  the  size  of  the  tube  and  the  nature  of  the 
electrodes  employed. 

A  large  tube  may  occupy  a  considerable  time  in  actual  exhaustion. 
During  the  process  various  conditions  have  to  be  observed,  and  it  is  during 
pumping  that  the  rmavoidable  risks  of  tube-making  are  greatest,  as  with 
the  increase  of  pressure  from  without,  any  stress,  flaw,  or  other  fault  may 
result  in  the  sudden  collapse  of  the  tube. 

When  exhaustion  is  complete,  the  tube  is  taken  from  the  pump,  sealed, 
tested,  and,  if  found  to  be  in  order,  is  finished  oi!  with  the  necessary 
terminals. 

The  Anti-cathode. — The  most  important  part  of  an  X-ray  tube  is 
the  anti-cathode,  since  it  is  here  that  the  heat  is  generated,  and  most  dis- 


30  KADIOGEAPHY 

turbances  take  place.     It  is  this  part  of  the  tube  which  is  exposed  to  the 
intense  force  of  the  cathode  stream. 

The  power  of  resistance  to  this  stream,  and  the  physical  effect  thereof, 
possessed  by  the  anti-cathode  of  the  tube  is  the  determining  factor  in  the 
life  of  the  X-ray  tube,  and  the  degree  of  current  it  will  stand  determines 
largely  the  amount  of  work  it  is  capable  of  performing. 

Naturally  the  anti- cathode 
varies  with  each  tube,  and  these 
are  now  made  for  special  pur- 
poses. 

A  careful  study  of  the 
various  types  of  anti -cathode 
in  use  will  be  necessary  before 
the  operator  can  thoroughly 
understand  the  best  conditions 
under  which  the  tube  will  work. 
The  anti-cathodes  of  some  tubes 
may  become  incandescent  when 
the  tube  is  running  at  full  cur- 
rent, and  a  careful  watch  is 
necessary  when  using  tubes  in 
/  this  way. 

/  The  cheaper  tubes  are  made 

/  with    light    anti -cathodes.     The 

/  next  class  of  anti-cathode  is  that 

/  known  as  the   "  heavy  anode," 

consisting  usually   of    a    copper 
tube  or  sleeve  of  varying  thick- 
FiG.  27.— Cyclops  radiator  tube.    (C.Andrews.)      ness   and   leng-fch,   and   carrying 

The  heat  generated  at  the  anti-cathode  is  absorbed  and   q^j^     j-^g      extremity     a     platinum- 
radiated  along  a  solid  copper  rod  which  is  arranged  ,11,        •      -i        .      -i      .  i 

to  lacilitatereadyremoval  from  the  tube.  When  the  COated  plate  Similar  tO  that  USed 
copper  is  heated  it  may  be  removed  and  a  second  [^  ^Jj^g  light  auodc  tubc.  In  this 
one  introduced.    By  changing  these  during  an  ex-  ' 

posure,  the  tube  can  be  kept  comparatively  cool  for  Case,  hOWever,  these  VariOUS 
long  periods,  the  vacimm  of  the  t^ibe  being  thereby  jj^etals  are  Welded  together  iuto 
maintained  at  a  constant  degree  of  hardness.  .  ^  . 

one  contmuous  whole,  wnicn  is 
supported  on  a  glass  sleeve  projecting  from  the  wall  of  the  tube.  Natur- 
ally this  mass  of  metal  has  much  greater  absorption  and  conductive 
capacity  than  the  Hght  anode,  and  will  in  consequence  stand  a  much  greater 
degree  of  heating,  i.e.  a  higher  current.  There  is  also  a  proportionately 
large  reserve  of  gas  in  these  armatures,  and,  unless  grossly  over-run,  such 
tubes  do  not  become  red-hot,  and  are  therefore  much  more  constant  in 
vacuum. 

As  the  weight  of  metal  in  the  anti-cathode  is  increased,  so  (other  condi- 
tions being  equal)  the  capacity  of  the  tube  to  withstand  a  high  current  is 
increased  also.  Occasionally,  the  metal  sleeve  of  the  anti-cathode  is  greatly 
extended,  and  is  carried  directly  to  the  exterior  of  the  tube,  terminating 


/ 


WATER-COOLED  TUBE 


sometimes  in  a  radiating  device  in  order  to  discharge  the  heat  as  expeditiously 
as  possible. 

As  the  difficulties  which  arise  in  heavy  currents  for  X-ray  work  are 
almost  wholly  concerned  with  such  heating,  several  other  methods  have  been 
adopted  in  order  to  deal  with  it  in  an  efficient  manner.  One  is  the  system 
on  which  the  Cyclops  tube  is  worked.  The  other  is  that  employed  in  water- 
cooled  models.     These  are  described  at  some  length  in  the  following  pages. 

Water-cooled    Tubes.— The  general  use  of  X-ray  tubes  cooled  by 
means  of  water  was,  for  all  prac- 
tical purposes,  commenced  by  the 
continental  radiographers. 

The  original  Miiller  water- 
cooled  tube  is  designed  mainly 
on  the  lines  suggested  by  Professor 
Walter.  It  is  arranged  in  the 
following  manner  :  In  place  of 
the  usual  heavy  metal  anti  - 
cathode,  a  solid  platinum  vessel 
is  provided,  and  on  to  the  bottom 
surface  of  this  is  fixed  a  metal 
plate  which  is  in  turn  faced  with 
platinum.  The  upper  or  open 
end  of  the  vessel  is  sealed  on  to 
a  glass  sieve,  which  is  in  turn 
attached  to  the  wall  of  the  tube, 
and  which  is  expanded,  outside 
the  tube,  into  a  reservoir  or  water 
chamber  approximately  3  inches 
diameter.  When  water  is  filled 
in,  it  passes  down  the  glass  sleeve 
to  the  platinum  vessel,  and  is  thus 
brought  into  actual  contact  with 
the  back  of  the  target.  This 
latter  feature  is  an  essential  in  the 
construction  of  a  water-cooled  tube.  Workers  are  strongly  advised  not  to 
purchase  so-called  water-cooled  tubes  when  the  water  does  not  reach  right 
down  to  the  back  of  the  target,  as  such  instruments  simply  omit  the  vital 
principle  which  renders  the  water-cooled  tube  so  highly  efficient. 

When  the  heat  is  generated  by  the  impact  on  the  target  it  is  immediately 
imparted  to  the  water,  and  the  temperature  of  the  target  can  therefore  only 
momentarily  exceed  that  of  boiling  water — 100°  C. 

Apart  from  the  efficiency  of  the  cooling  system,  the  construction  of 
water-cooled  tubes  renders  them  more  satisfactory  in  other  respects.  In 
the  first  place  it  is  possible  to  make  the  anti-cathode  almost  entirely  of 
platinum,  which  means  that  there  is  practically  no  metal  in  the  tube  likely 
to  give  rise  to  violent  changes  of  vacuum.     The  water-cooled  tubes  remain 


Fig.  28. 


-Water-cooled  tube  arranged  for  overhead 
work.      (C.Andrews.) 


32  EADIOGEAPHY 

therefore  at  approximately  the  same  degree  of  hardness  for  very  long  periods. 
The  great  advantage  in  this  respect  cannot  be  over-estimated,  and  will 
appeal  both  to  those  who  are  doing  continuous  radiographic  work,  and  to 
those  running  tubes  for  long  periods  for  therapeutic  purposes.  The  latter 
point  is  of  extreme  importance  for  deep  therapeutics. 

The  employment  of  water  as  a  cooling  medium  is  free  from  all  objection, 
even  from  that  of  extra  trouble  in  manipulation  ;  for  if  tubes,  when  not 
actually  running,  are  stored  in  one  of  the  excellent  vertical  holders  now  on 
the  market,  it  is  not  necessary  even  to  empty  the  water  bulb  after  use,  and 
the  only  extra  attention  entailed  is  the  occasional  replacing  of  the  water 
which  may  be  lost  by  evaporation. 

The  principal  feature  of  water-cooled  tubes  is  that  they  may  be  kept 
in  continual  use  for  hours,  without  any  danger  of  over-heating  and  consequent 


X./ 


Fig.  29. — Water-cooled  tube  for  overhead  or  under  the  couch  work,  showing  mica 
and  carbon  regulator.      (C.  Andrews.) 

softening.  Further,  they  will  withstand  a  much  larger  current  than  the 
ordinary  tube  will  take,  and  in  fact  the  heavier  models  will  for  a  short  time 
stand  up  against  the  maximum  amount  of  current  which  can  be  forced 
through  them. 

Selection. — In  selecting  a  water-cooled  tube,  regard  must  be  paid  to  the 
class  of  work  which  is  intended  to  be  done.  It  must  be  considered  whether 
the  tube  is  to  be  used  with  light  or  heavy  currents,  and  whether  it  is  to  be 
used  only  above  the  couch  (either  horizontally  or  vertically),  or  whether  it 
is  desired  that  it  may  be  used  in  the  horizontal  position  from  below  the 
couch. 

The  tubes  for  use  below  the  couch  are  made  with  the  anti-cathode  set 
in  the  long  axis,  and  are  furnished  with  a  curved  revolving  tube,  by  means 
of  which  the  water  is  prevented  from  flowing  out.  The  tubes  for  use  in 
positions  other  than  below  the  couch  have  the  anti-cathode  set  at  an  angle 
of  45°  to  the  long  axis. 

Tubes  for  use  with  heavier  currents  are  made  on  an  exactly  similar 


THE  USE  OF  WATER-COOLED  TUBES  33 

system  to  the  lighter  models,  but  differ  in  that  the  armatures  are  strengthened 
in  order  to  permit  of  the  heavier  loads  being  carried.  The  most  important 
modification  is  in  the  anti-cathode,  which  is  made  in  the  following  way  : 
The  platinum-faced  target  is  set  on  a  massive  block  of  specially  alloyed 
copper,  which  is  in  turn  attached  to  a  solid  platinum  vessel  similar  to  that 
used  for  the  lighter  models.  By  the  interposition  of  this  buffer  of  alloy 
the  capacity  of  the  tube  is  enormously  increased,  and  at  the  same  time  the 
amount  of  extra  metal  thus  introduced  is  not  sufficient  to  rob  the  tube  of 
its  excellent  qualities  of  constancy  and  steady  working.  In  fact  the  whole 
proportioning  and  "  balance  "  of  these  tubes  has  been  worked  out  with  a  nice 
exactness  which  has  been  amply  justified  by  the  result. 

The  Use  of  Water-cooled  Tubes. — It  must  be  remembered  that  this  type 
of  tube  is  designed  and  constructed  to  work  with  a  water-jacket,  and  it 
must  on  no  account  be  used  without  the  receptacle  having  been  filled  to 
within  about  half  an  inch  of  the  top.  In  the  case  of  the  pattern  for  use  above 
and  below  the  patient,  the  opening  of  the  curved  tube  should  be  just  above 
the  surface  of  the  water,  when  the  instrument  is  placed  horizontally,  thus 
allowing  an  outlet  for  steam.  If  the  tube  should  be  inadvertently  worked 
without  water,  it  must  be  allowed  to  cool  completely  down  (say,  for  at 
least  an  hour)  before  water  is  filled  in.  If  this  precaution  is  not  observed, 
a  breakage  will  in  all  probability  occur. 

As  stated  above,  it  is  not  necessary  to  remove  the  water  after  using, 
and,  therefore,  there  should  be  little  danger  of  the  tube  being  worked  without 
the  cooling  medium. 

Ordinary  tap  water  should  be  employed,  not  distilled  nor  filtered. 
Should  the  tube  have  been  running  continuously  so  that  the  water  is  boiling, 
it  is  permissible  to  renew  the  supply,  and  this  may  be  done  without  disturbing 
the  tube,  by  means  of  a  syphon.  By  placing  a  vessel  containing  water 
at  a  lower  level  than  the  tube  and  starting  the  flow  by  suction,  the  water 
may  be  run  out  until  only  about  3  inches  of  the  water-tube  remain  filled. 
The  container  is  then  raised  to  a  level  above  the  tube,  and  water  allowed 
to  flow  in.  If  no  syphon  is  obtainable,  an  alternative  method  is  the  following : 
Pour  the  boiling  water  out  of  the  tube  into  a  jug,  and  add  cold  water  in 
sufficient  quantity  to  render  the  whole  just  distinctly  warm  to  the  touch. 
Then  refill  the  water-chamber  with  the  slightly-warmed  water.  Obviously, 
if  the  boiling  water  were  removed,  and  cold  water  filled  in,  the  glass  might 
possibly  fracture  ;  but  by  adopting  the  above  method  the  supply  may  be 
safely  renewed.     The  tube  may  then  be  run  as  before. 

In  cases  where  the  tubes  are  used  in  a  horizontal  position,  care  should 
be  taken  to  raise  the  water-chamber  slightly  above  the  level  of  the  anti- 
cathode  itself,  so  as  to  keep  the  water  against  the  target.  This  prevents 
the  water  flowing  away  from  the  anti-cathode,  as  it  might  do  if  the  tube 
were  absolutely  horizontal,  and  also  allows  of  the  escape  of  bubbles,  etc. 
The  curved  tube  in  the  cap  may  be  revolved  according  to  the  position  of  the 
X-ray  tube,  so  as  to  permit  of  the  aperture  being  always  uppermost. 

If  desired,  the  water  can  be  circulated  through  the  tube  by  means  of  the 

3 


34  EADIOGEAPHY 

syphon  mentioned  above.  This  is  very  efficacious,  but  necessary  only  when 
very  lengthy  runs  are  being  undertaken. 

There  is  another  type  of  tube  made  by  several  makers  which  is  very 
efficient  and  convenient  for  treatment.  This  tube  has  a  diameter  of  about 
5  inches  (125  mm.).  As  will  be  seen  from  Fig.  215,  p.  295,  an  auxiliary  bulb 
(having  a  diameter  of  about  6|  inches)  is  connected  to  the  tube,  thus 
forming  a  reserve  air-chamber.  This  construction  results  in  the  tube 
possessing  all  the  advantages  inseparable  from  one  having  a  large  cubic 
capacity ;  while  the  fact  of  the  anti-cathode  being  only  2|  inches  from 
the  wall  of  the  tube  enables  the  original  Sabouraud  distance  to  be  adopted. 

Air-cooled  Tube. — -The  tube  employed  is  specially  constructed, 
an  air  pump  being  employed  to   supply  a  forced  draught  which  is  sent 


Fig.  30. — Dessneur  tabe  with  atomiser  for  cooling  the  anti-cathode.     (Siemens.) 
This  tube  is  specially  exhausted  for  deep  therapeutic  work. 

into  the  cathode  and  anti-cathode  of  the  tube.  By  means  of  the  small 
electric  motor  operating  the  force-pump,  air  at  the  temperature  of  the  room 
is  used  at  considerable  pressure.  The  special  modifications  of  the  tube 
required  are  as  follows  :  In  place  of  the  ordinary  cathode  there  is  employed 
a  very  massive  hollow  armature,  with  the  same  diameter  as  the  anti-cathode  ; 
into  both  cathode  and  anti-cathode  are  fitted  inlet  tubes,  which  bring  the 
cold  air  into  direct  contact  with  the  whole  inner  surface  of  the  armature, 
and  the  heated  air  is  expelled  through  a  number  of  peripheral  apertures. 
The  connection  between  the  X-ray  tube  and  the  air  pump  is  made  by  means 
of  strong  uidia-rubber  tubes.  The  cathode  is  cooled  as  efficiently  as  the 
anti-cathode,  this  being  a  very  important  point.  In  a  tube  of  this  type, 
currents  of  at  least  5  to  7  milliamperes  may  be  passed  continuously  without 
any  ill  ejSects. 

There  has  been  introduced  a  further  elaboration  of  this  type  of  tube, 
i.e.  a  tube  working  as  described  above  but  fitted  in  addition  with  an  atomiser 
connected  to  a  vessel  containing  water.     Instead,  therefore,  of  air  being 


THE  GUNDELACH  TUBE  35 

pumped  on  the  back  of  the  anti-cathode  the  water  is  continuously  sprayed 
on  the  latter  and  thus  cools  the  electrodes. 


Fig.  31. — Heavy  anode  tube  (Gundelach).     Osmosis  regulator.     (Siemens.) 

Gundelach  Tube. — The  tube  figured  above  is  the  ordinary  Gundelach 
tube  with  Osmosis  regulator.  There  has  just  been  introduced  a  new  tube 
by  Gundelach  which  appears  to  possess  some  special  advantages  for  deep 
therapeutic  work.  It  is  not  of  the  usual  outward  form  but  cone-shaped, 
with  the  anti-cathode  near  the  point  of  the  cone  and  the  terminals  and 
regulator  at  the  base,  so  that  the  tube  can  be  brought  very  near  to  the  part 
to  be  irradiated,  and  at  the  same  time  the  high-tension  terminals  are  some 
distance  away.  Further,  the  tube  is  made  to  be  used  in  a  specially  thick 
lead-glass  shield  with  a  celluloid  window,  and  on  the  outside  of  the  window 
is  an  arrangement  for  attaching  aluminium  filters  of  various  thicknesses. 
The  tube  is  arranged  for  air-cooling  by  means  of  a  forced  air-pump,  and 
two  feeding  tubes  from  the  pump  are  arranged  so  that  one  is  connected  to 
the  pipe  leading  to  the  back  of  the  anti-cathode,  and  the  other  to  the  inside 
of  the  protective  lead-glass  shield  in  order  to  keep  the  outside  of  the  tube 
cool.  The  pump  connections  are  worthy  of  notice,  the  particular  feature 
being  that  the  air  is  fed  from  the  pump  to  a  water-cooling  chamber, 
which  is  essential  for  successful  cooling,  otherwise  it  will  be  found  that  the 
air,  after  the  pump  has  been  running  for  some  time,  becomes  warm,  but  after 
passing  through  the  cooler  it  is  reduced  to  the  temperature  of  the  room,  and 
will  remain  at  this  temperature  for  hours  without  changing  the  water. 
With  such  a  tube  and  air-pump  combination  it  is  possible  to  work  for  con- 
siderable periods  with  large  milliamperages. 

Coolidg'e  Tube. — At  the  time  of  writing  this  book  an  announcement 
comes  from  America  of  a  tube  which  has  been  invented  by  D.  D.  Coolidge, 
which  appears  to  be  of  such  novel  construction  as  to  make  it  the  greatest 
advance  that  has  taken  place  since  the  discovery  of  X-rays. 

The  tube  is  devised  to  be  entirely  free  of  gas  and  has  a  vacuum  1000 
times  greater  than  the  ordinary  tube,  so  that  it  is  impossible  to  pass  a  current 
through  it  in  the  ordinary  way  even  with  the  most  powerful  apparatus. 
The  anti-cathode  is  constructed  of  tungsten,  and  the  cathode,  instead  of 


36 


RADIOGKAPHY 


being  an  aluminium  cup-shaped  electrode,  consists  of  a  spiral  of  tungsten 
wire  surrounded  by  a  sleeve  of  molybdenum  to  focus  the  cathode  stream. 
Connected  to  the  cathode  spiral  is  an  auxiliary  source  of  current  consisting 
of  a  small  accumulator  battery  with  an  ammeter  in  circuit  (it  is  important 
that  the  battery  is  well  insulated  from  earth),  which  heats  the  metal,  causing 
it  to  give  of?  a  stream  of  negatively- charged  electrons  which  are  projected 
on  to  the  anti-cathode. 

The  number  of  freed  electrons  from  the  anti-cathode  is  regulated  by 
the  degree  of  heating  of  the  tungsten  spiral,  and  the  speed  of  the  cathode 


Fig.  32. — Coolidge  X-ray  tube.      (British  Thomson  Houston. ) 

stream,  upon  which  depends  the  penetrating  power  of  the  X-rays,  is  regulated 
by  increasing  or  diminishing  the  potential  at  the  terminals  of  the  tube. 

It  is  claimed,  therefore,  that  this  tube  will  give  us  accuracy  of  adjust- 
ment, stability  of  hardness,  possibility  of  exact  duplication  of  results,  un- 
limited life,  great  range  of  flexibility,  absence  of  inverse  radiation,  and 
extremely  large  output.     The  chief  feature  seems  to  be  that  one  can  at  will 


Fig.  33. — Diagram  of  Coolidge  tube. 

have  any  degree  of  hardness,  and  any  quantity  of  rays,  and  these  two  factors 
constant  for  indefinite  periods,  and  can  also  repeat  the  same  conditions  at 
any  time.  The  most  remarkable  and  valuable  advantage  is  that  indicated 
by  its  immense  output  for  deep  therapeutic  work,  and  also  for  instantaneous 
radiography.  There  is  one  note  of  warning,  and  that  is  that  this  tube 
gives  Httle  or  no  visible  sign  of  fluorescence,  so  that  extra  precautions  must 
be  taken  ;  otherwise,  owing  to  its  much  greater  output,  a  serious  burn 
can  be  produced,  the  margin  of  safety  being  practically  nil,  whereas  one 
cannot  run  the  ordinary  form  of  tube  continuously  with  a  heavy  current. 

Connections. — The  accompanying  illustration  shows  the  tube  properly 
connected  to  the  storage  battery  and  the  terminals  from  the  coils.  It  must 
always  be  home  in  mind  that  the  entire  battery  circuit  is  brought  to  the  full 


THE  COOLIDGE  TUBE 


37 


potential  of  the  tube,  and  that  it',  therefore,  has  to  he  as  thoroughly  insulated  both 
from  the  patient  and  the  ground  as  has  the  tube  itself. 

The  full  circuit  is  shown  in  Fig.  35,  in  which  S  is  the  parallel  spark 
gap,  M  the  milhammeter,  B  the 
storage  battery,  E  the  rheostat 
for  controlling  the  current  in 
the  filament  circuit,  and  A  an 
ammeter  for  measuring  this 
current.  (A  is  not  shown  in 
the  illustration.  It  is  a  con- 
venience and  not  a  necessity.) 
As  the  diagram  shows,  the 
resistance  is  all  in,  and  hence 
the  filament  temperature  is 
lowest  when  the  rheostat  handle 
is  pushed  as  far  as  possible  away 
from  the  operator. 

If  the  polarity  of  the 
machine  is  wrong,  it  will  be 
shown  by  the  fact  that  the 
milliammeter  will  register  no 
current,  regardless  of  how  high 
the  filament  temperature 
may  be. 


Fig.  34.— Complete  Coolidge  X-ii, 
(B.T.H.) 


;piin-ia  ill  |jo.^ition. 


The  Battery.~A  convenient  size  is  a  5  or  6  cell  (10  or  12  volt)  40  am- 
pere-hour battery,  and  it  will  be  found  much  more  satisfactory  if  arrange- 
ments are  made  so  that  the  battery  can  be  connected  either  every  night 

or  else  whenever  not  in 
use  during  the  day,  to 
the  charging  circuit.  In 
some  cases  it  will  be 
found  convenient  to 
have  the  battery  stand 
on  the  floor,  while  in 
others  it  may  advan- 
tageously be  placed 
higher  up  on  a  shelf. 
In  the  latter  case  it  will 
be  necessary  to  re-locate 
the  rheostat  on  the  back 
of  the  stand,  so  that  the 
.  handle  will  point  in  the 

right  direction.  Both  the  rheostat  handle  and  the  cord  attached  to  the 
pull  switch  (m  the  battery  circuit)  should  be  brought  through  the  lead 
screen  which  protects  the  operator,  and  to  a  point  within  easy  and  con- 
vement  reach. 


Fig.  35.— Diagram  of  connections  for  Coolidge  tube. 


38  EADIOGRAPHY 

Method  of  Operating. — The  technique  of  various  operators  and  the 
sources  of  excitation  vary  so  much  that  it  is  difficult  to  make  very  detailed 
suggestions.  The  following  general  considerations,  however,  may  be  of 
value. 

The  higher  the  filament  temperature,  the  greater  the  discharge  current. 

The  higher  the  voltage  backed  up  by  the  tube,  the  higher  the 
penetration. 

A  simple  method  for  starting  radiographic  work  with  the  tube  is  as 
follows  : 

Take  a  case,  for  example,  where  the  operator  has  been  setting  his 
rheostat  on  the  10th  button,  and  adjusting  his  tube  to  where  it  then  draws 
30  milhamperes.  In  this  case,  all  that  is  necessary,  with  the  Coohdge  tube, 
is  to  set  the  rheostat  on  the  10th  button,  light  up  the  filament  in  the  tube, 
having  the  handle  pushed  as  far  away  as  possible,  close  the  main  switch,  and 
pull  on  the  rheostat  handle  until  the  tube  is  drawing  30  milliamperes.  The 
main  switch  is  then  opened,  and  the  operator  is  ready  to  make  liis  exposure. 

In  other  cases,  the  radiographer  will  be  accustomed  to  adjust  the  tube 
by  means  of  the  milliammeter  and  the  parallel  spark-gap.  This  procedure 
can  be  applied  equally  well  to  the  Coolidge  tube,  and  will  naturally  be  the 
one  first  used  in  all  cases  where  the  operator  is  not  familiar  with  his  machine. 
KnoAving  that  he  wants,  for  example,  20  milliamperes  and  a  5-inch  parallel- 
gap,  he  will  start  with  the  battery  rheostat  handle  pushed  well  away  from 
him,  and  with  his  main  rheostat  set  on  a  low  button.  He  will  then  pull 
on  the  battery  rheostat  handle,  and  run  up  to  higher  buttons  on  the  main 
rheostat,  until  the  tube  is  drawing  20  milliamperes  and  backing  up  the 
5-inch  gap. 

The  tube  may  be  safely  run  with  the  target  at  white  heat.  If  excessively 
high  energy  inputs  are  employed,  the  tungsten  at  the  focal  spot  melts  and 
volatihses.  This  results  in  a  sudden  lowering  of  the  tube  resistance  and  in 
blackening  of  the  bulb.  The  instabihty  in  resistance  disappears  instantly 
upon  lowering  the  energy  input,  and  no  harm  has  been  done  to  the  tube, 
that  is,  unless  it  is  to  be  used  for  the  production  of  the  most  penetrating  rays 
which  it  is  capable  of  emitting.  In  this  case,  a  heavy  metal  deposit  on  the 
bulb  is  undesirable,  as  it  interferes  with  smooth  running  at  such  high  voltages. 

The  tube  should  not  be  run  with  voltages  higher  than  that  corresponding 
to  a  10-inch  spark-gap  between  points  (that  is,  it  should  not  be  made  to 
back  up  more  than  a  10-inch  parallel-gap). 

For  long-continued  running  in  an  enclosed  space  and  with  heavy  energy 
inputs,  it  will  be  necessary  to  provide  some  means  of  coohng  the  glass,  as  by 
a  small  fan  or  blower.  The  glass  can,  however,  safely  be  allowed  to  get  very 
hot.     It  is  all  right  so  long  as  it  does  not  soften  and  draw  in. 

In  running  the  tube  on  a  coil,  a  valve  tube  should  be  used  when  heavy 
energy  inputs  are  to  be  employed.  So  long,  however,  as  the  temperature  of 
the  focal  spot  is  not  made  to  approximate  that  of  the  cathode,  the  tube  will 
satisfactorily  rectify  its  own  current. 

There  are  tubes  made  in  America  which  differ  from  the  types  usually 


THE  PRODUCTION  OF  X-RAYS  39 

made  on  the  Continent  and  in  England,  in  that  they  are  exhausted  by  a 
special  process,  and  as  no  mercury  is  employed  in  the  pumping  it  is  impossible 
for  mercury  vapours  to  find  their  way  into  the  tube  ;  this  enables  the  tube 
to  be  exhausted  "  hard  "  in  the  first  instance.  The  tube  is  hard  from  the 
beginning,  and  does  not  therefore  require  to  be  carefully  worked  up  for 
radiographic  or  therapeutic  work.  It  may  be  used  at  once  for  deep  work. 
The  tube  may  require  to  be  regulated  if  it  is  too  hard.  These  new  tubes 
are  fitted  with  a  special  form  of  cathode,  which  prevents  the  concentration 
of  heat  at  the  neck  of  the  cathode.  They  are  consequently  not  so  Kable  to 
break  down  when  overloaded. 

The  evolution  of  this  type  of  tube  in  America  is  no  doubt  due  to  the 
fact  that  workers  there  are  using  more  powerful  apparatus  for  X-ray  work, 
and  have  had  to  produce  a  tube  which  will  stand  up  to  the  heavy  currents 
generated  by  such  apparatus. 

The  Production  of  X-Rays. — When  a  current  of  electricity  from  an 
induction  coil  is  passed  through  an  X-ray  tube,  a  beam  of  cathode  rays 
from  the  concave  cathode  is  focussed  on  the  target  or  anti-cathode,  the 
surface  of  which  is  inclined  at  an  angle  of  45°  to  the  rays.  The  anti-cathode 
islusually  made  of  a  metal  of  high  atomic  weight,  such  as  platinum,  tungsten, 
etc.  The  anode  and  cathode  are  usually  of  aluminium  ;  from  the  point  of 
contact  of  the  cathode  stream  on  the  anti -cathode,  X-rays  are  given  out  in 
all  directions.  X-rays  are  invisible,  and  do  not  make  glass  fluorescent.  The 
pale-green  hemisphere  of  fluorescence  on  the  bulb  is  due  to  reflected  cathode 
rays  from  the  anti-cathode  striking  the  glass  of  the  tube.  This  may  be 
clearly  shown  by  the  action  of  a  magnet  on  the  boundary  of  the  fluorescence. 
X-rays  are  not  deflected  by  the  proximity  of  a  magnetic  field.  The  pressure 
of  the  gas  in  an  X-ray  tube  becomes  lower  with  use,  and  a  device  for  softening 
the  tube  {i.e.  raising  the  pressure  of  the  gas  in  the  bulb)  is  therefore  usually 
provided.  The  higher  the  pressure  the  less  is  the  potential  required  to 
work  the  tube,  and  the  less  the  penetration  of  the  rays.  The  X-rays  produced 
and  the  condition  of  the  tube  are  termed  "  soft  "  if  the  pressure  of  gas  in  the 
bulb  is  high.  The  lower  the  pressure  the  harder  are  the  rays.  The  cathode 
of  the  tube  is  made  of  aluminium,  and  is  fixed  just  within  the  neck  of  a  side 
tube  to  the  bulb  ;  it  is  concave.  As  the  exhaustion  of  the  tube  proceeds,  the 
focus  of  the  rays  recedes  farther  and  farther  from  the  cathode,  and  may 
reach  a  distance  of  something  like  four  or  five  times  the  radius  of  curvature 
of  the  cathode. 

The  relative  positions  of  cathode  and  anti-cathode  is  a  matter  of  experi- 
ence with  the  maker.  The  anti-cathode  is  usually  mounted  a  Uttle  out  of 
focus  to  avoid  its  early  destruction  by  fusion,  the  result  of  the  extreme  heat 
generated  at  the  focus  point.  When  sharp  radiographic  work  has  to  be  done 
the  focus  must  be  exceedingly  sharp.  Some  makers  turn  out  tubes  with  a 
very  sharp  focus,  and  excellent  radiographs  are  obtained  with  such  tubes. 
The  drawback  to  the  tubes  is  the  comparatively  short  time  they  last. 

The  Anti-cathode  of  the  X-ray  Tube. — The  requirements  of  an  anti- 
cathode  intended  for  modern  radiographic  work  are  : 


40 


KADIOGEAPHY 


(1)  A  high  atomic  weight  to  secure  a  large  quantity  of  rays. 

(2)  A  high  melting  point  to  permit  sharp  focussing. 

(3)  A  high  thermal  conductivity. 

Appearance  of  the  X-Ray  Tube  in  Action. — ^^^^hen  the  X-ray  tube 
is  connected  properly  one-half  of  the  tube  between  the  cathode  and  anti- 


FiG.  36. — Connections  of  the  X-ray  tnbe  to  the  FiG.  37. — Connections  of  the  X-ray  tube  to  the 

coil,    showing   the    route    travelled   by    the  coil,  showing  the  apj^earance  when  the  poles 

spark  when  the  point  is   the  positive  pole  are  reversed. 
and  the  negative  the  plate. 

cathode  looks  as  if  it  were  evenly  filled  with  green  light,  the  other  half 
of  the  tube  behind  the  anti-cathode  remaining  dark,  because  the  anti-cathode 
acts  as  a  screen. 

If  wrongly  connected  there  is  an  irregularly  patchy  fluorescence  of  the 

^^  walls  of  the  tube,  and  rays  appear 
at  intervals  which  change  con- 
siderably according  to  the  amount 
of  current  passing  through  the 
tubes. 

For  the  appearance  of  the 
X-ray  tube  when  correctly  and 
incorrectly  in  operation,  see  the 
coloured  frontispiece. 

The  important  thing  to  re- 
member is  first  of  all  to  ascertain 
the  polarity  of  the  coil.  This  is 
done  by  testing  with  the  spark- 
gap. 

Selection  and  Regulation 
of  X-Ray  Tubes. — Little  need  be 
said  on  this  point.  As  nearly  all 
the  tubes  on  the  market  are  now 
good,  the  particular  type  selected 
depends  to  a  large  extent  upon  the  operator.  When  possible  a  number 
of  good  tubes  should  be  kept  in  constant  use.  A  tube  which  is  in 
good  condition  and  has  a  sharp  focus  should  be  reserved  for  radio- 
graphic work ;  for  therapeutics  a  tube  with  a  diffused  focus  is  better  than 
a  sharp  one  because  it  will  last  longer.  This  requires  to  be  taken  with 
reserve.  Some  workers  prefer  to  use  a  sharp  focus  for  therapeutic  work. 
It  may  be  that  the  sharp  focus  of  the  cathode  stream  upon  the  anti-cathode 
may  generate  a  beam  of  X-rays  of  particularly  good  therapeutic  value. 

Unless  for  special  purposes  it  is  always  better  to  purchase  tubes  of  a 
medium  vacuum,  inclining  towards  the  soft  side.     A  tube  of  large  diameter. 


Fig.  38. — Connection  of  X-ray  tube  to  the  coil, 
showing  coil  and  connections  to  tube.  A 
valve  tube  is  inserted  on  the  negative  j)ole. 


SELECTION  AND  KEGULATION  OF  X-RAY  TUBES  41 

7  or  8  inches,  will  continue  to  keep  good  vacuum  longer  than  a  smaller  tube. 
For  heavy  currents,  either  in  radiographic  or  therapeutic  work,  the  larger 
tube  will  in  the  end  be  found  most  economical. 

The  chief  advantage  of  having  several  tubes  in  use  is  that  the  very  soft 
tube  may  be  used  for  short  exposures  and  gradually  worked  up  for  thicker 
parts.  Then  with  about  half  a  dozen  tubes  all  parts  oi  the  body  may  be  radio- 
graphed with  a  tube  in  proper  condition  for  the  part.  New  tubes  are  gener- 
ally soft  and  require  to  be  gradually  worked  up  in  hardness  before  they  can 
be  used  for  the  deeper  parts  of  the  body.  It  is  a  good  plan  to  reserve  new 
tubes  for  short  exposures  of  the  thinner  parts  such  as  the  hands,  ankles, 
etc.  After  a  few  weeks  of  such  work  a  new  tube  may  then  be  used  for  the 
knees,  shoulders,  and  elbows. 

Later,  when  the  tube  has  become  seasoned,  it  can  be  used  for  the  longer 
exposures  required  for  radiography  of  the  kidney  areas,  spine,  and  skull. 

A  new  tube  should  never  be  overrun,  that  is,  long  exposure  with  large 
currents  should  not  be  used,  because  if  they  are,  the  vacuum  may  be  hope- 
lessly reduced,  and  the  tube  will  then  require  to  be  re-exhausted.  Once 
a  tube  is  seasoned  it  will  maintain  its  vacuum  and  degree  of  hardness  for 
long  periods,  and  may  be  used  for  hours  daily.  The  amount  of  usage  to 
be  got  from  a  tube  which  has  been  thoroughly  seasoned  is  surprismg. 

Sometimes  a  tube  after  repeated  short  exposure  may  not  harden. 
A  good  plan  is  to  run  such  a  tube  for  half  an  hour  to  one  hour  on  the 
minimum  current  available.  A  |  milliampere  through  a  tube  for  several 
runs  of  that  duration  may  succeed  in  bringing  it  into  a  working  condition. 
It  should  be  treated  carefully  for  several  weeks. 

The  majority  of  tubes  after  prolonged  use  tend  to  harden.  This  natural 
hardening  from  use  may  be  combated  in  several  ways.  The  best  of  all  is 
to  regulate  the  tube  by  varying  the  intensity  of  the  current  passing  through 
the  bulb.  A  tube  too  hard  for  the  object  we  desire  to  examine  can  be  brought 
back  to  the  proper  degree  by  allowing  a  fairly  strong  current  to  pass  for 
several  minutes.  If  the  current  used  is  not  sufficient  for  this  purpose,  pass 
a  very  heavy  current  for  a  moment. 

A  time  comes  with  all  tubes  when  we  must  use  the  mechanical  regulator, 
the  same  remark  appl3ring  to  valve  tubes.  The  form  of  regulator  varies 
with  the  make  of  the  tube,  and  all  require  some  understanding  before  we 
can  properly  use  them.  In  all  cases  it  is  better  to  begin  reducing  the  tube 
with  a  minimum  quantity  of  current  and  a  fairly  large  interval  of  space 
between  the  cathode  terminal  and  the  regulating  rod.  The  distance  can 
easily  be  diminished,  the  important  point  being  not  to  overdo  the  reduction. 

When  radiographing  some  parts  of  the  body  we  estimate  the  degree  of 
hardness  of  the  tube  by  one  of  the  methods  enumerated,  i.e.  alternative 
spark-gap,  Wehnelt  radiometer,  Benoist  scale,  and  then  place  the  regulating 
rod  of  the  tube  at  the  half  distance  of  the  spark-gap  required,  and  allow 
current  to  pass  through  the  tube.  Sparking  at  once  goes  on  between  the 
two  points,  and  some  gas  is  liberated  in  the  glass  cylinder  at  the  end  of  the 
regulator.     The  gas  passes  into  the  interior  of  the  bulb,  the  shadow  on  the 


42  EADIOGEAPHY 

screen  is  altered,  and  the  sparking  ceases.  Make  sure  that  the  regulat- 
ing rod  is  taken  well  away  from  the  cathode  before  actually  making  the 
exposure,  as  a  good  tube  may  be  hopelessly  ruined  if  this  simple  pre- 
caution is  not  taken. 

The  various  devices  for  regulation  of  the  vacuum  of  a  tube  are  illustrated 
on  the  tubes.  The  best  of  all,  and  one  which  gives  the  operator  a  perfect 
control  over  the  tube  when  working,  is  the  air  valve  of  Bauer.  This  valve 
can  be  attached  to  any  tube  or  valve,  and  is  undoubtedly  a  great  help  to 
the  operator.  Dr.  Loose  of  Bremen,  who  has  used  this  regulator  extensively, 
speaks  very  favourably  of  it,  and  indeed  has  abandoned  all  other  forms 
in  its  favour.  In  using  it,  care  should  be  taken  not  to  introduce  air  too 
rapidly,  and  to  introduce  just  sufficient  to  maintain  the  balance  of  the 
vacuum.  One  can  readily  judge  of  the  action  if  the  tube  is  observed  care- 
fully while  reduction  is  going  on. 

The  tube  may,  however,  get  too  hard  for  regulation.  It  is  then  a  good 
plan  to  transfer  that  tube  to  another  apparatus  of  greater  strength.  A  tube 
which  has  hardened  on  a  mercury  break  may  act  perfectly  if  placed  on 
an  installation  with  an  electrolytic  break.  The  primary  current  is  much 
greater  in  the  latter  case,  the  secondary  is  greater,  and  there  is  more  heat 
generated  in  the  tube,  with  the  result  that  the  vacuum  tends  to  fall  and  the 
tube  to  soften.  A  hopelessly  hard  tube  should  be  put  away  for  several 
weeks  in  a  warm  corner  of  the  X-ray  room  or  placed  in  an  oven  for  several 
hours.  This  may  help  to  reduce  it  sufficiently  to  allow  it  to  be  used,  and 
then  by  regulating  the  current  carefully  it  may  be  possible  to  use  it  for 
some  time. 

When  a  tube  has  been  used  for  a  long  time  and  gets  too  hard  for  work 
it  is  better  to  sacrffice  it  altogether.  Re-exhaustion  and  remaking  of  the 
tube  costs  in  many  instances  nearly  as  much  as  a  new  one,  and  these  re- 
exhausted  tubes  are  never  so  reUable  as  a  new  one.  Consequently  it  is 
better  to  break  up  the  tube,  and  have  the  valuable  parts  used  for  the 
construction  of  a  new  tube  than  to  have  it  re-exhausted. 

There  are  many  other  points  in  the  management  of  the  X-ray  tube 
which  must  be  learned  as  the  result  of  experience.  The  fact  must  always 
be  borne  in  mind  that  it  is  the  tube  which  is  the  determining  factor  in  radio- 
graphy, and  too  great  care  cannot  be  taken  of  the  X-ray  tubes  when  in  or 
out  of  use.  Powerful  currents  if  instantaneous  do  not  harm  the  tube,  but  if 
prolonged  the  vacuum  is  lowered  and  the  tube  ruined.  The  quicker  the 
exposure  the  more  useful  is  the  resulting  radiograph  Hkely  to  be.  It  should 
be  noted  that  when  a  tube  is  used  for  all  purposes,  i.e.  screening  and  radio- 
graphy with  heavy  discharges,  the  balance  of  the  tube  is  often  seriously 
disturbed,  regulation  being  then  a  matter  of  increasing  difficulty.  It  is 
a  good  plan  to  keep  one  tube  for  screening  and  another  for  heavy 
work. 

The  efiect  of  the  most  powerful  impulse  on  the  tube  is  hardly  perceptible, 
a  current  of  100  milhamperes  or  more  passing  through  a  tube  for  the  tu-q  oi 
a  second  leaving  hardly  any  trace  on  the  anti-cathode.     This  current  may 


THE  MANIPULATION  OF  THE  X-RAY  TUBE 


43 


be  employed  on  the  cheapest  form  of  tube  wdthout  injuring  it.  There  is, 
however,  a  tendency  for  a  part  or  the  whole  of  the  current  to  arc  round  the 
tube  if  the  vacuum  is  too  high,  consequently  tubes  with  long  stems  or  necks 
are  necessary  if  hard  ones  are  to  be  used.  With  these  powerful  impulses 
the  soft  tubes  give  the  best  results. 

While  for  the  taking  of  instantaneous  pictures  the  most  powerful  installa- 
tions are  the  best,  it  must  be  pointed  out  that  quite  good  rapid  radiographs 
can  be  produced  by  the  use  of  installations  of  moderate  power,  provided  the 
operator  knows  the  apparatus  he  is  using,  and  particularly  if  he  possesses  that 
knowledge  of  the  X-ray  tube  which  is,  after  all,  the  chief  essential. 

The  Manipulation  of  the  X-ray  Tube. — The  X-ray  tube  should 
whenever  possible  be  placed  at  a  distance  of  at  least  6  or  7  feet  from  the 
source  of  energy  (coil,  etc.).  If  used  within  this  distance  there  is  a  probability 
that  the  magnetic  field  may  af!ect  the  cathodal  stream,  and  thus  alter  the 
focus  of  the  tube. 

When  the  tube  is  supported  by  any  form  of  clamp,  the  latter  should 
grip  the  cathodal  neck,  below  the  level  of  the  concave  cathode,  this  being 
the  strongest  part,  and  should  not 
clamp  it  too  tightly.  Before  turn- 
ing on  the  current,  the  tube  should 
be  carefully  dusted,  or  dried  if  there 
is  any  moisture  present. 

The  positive  pole  of  the  coil  or 
other  apparatus  should  be  connected 
by  well-insulated  cables  to  the  anti- 
cathode  of  the  tube,  and  the  nega- 
tive pole  to  the  cathode.  It  should 
be  seen  that  all  loose  wires  or  metal 
fittings  are  quite  clear  of  the  tube. 

The  regulating  wire  should  be 
placed  well  back  from  the  cathode 
— say,  at  a  distance  of  6  or  7  inches. 
The  point  is  emphasised  in  another 
portion  of  this  work.  There  are  exceptions  to  this  rule  in  the  manipulation 
of  those  tubes  which  work  best  with  the  regulator  at  a  fixed  distance  from 
the  cathode,  according  to  the  hardness  of  the  particular  tube  and  the 
purpose  for  which  it  is  being  used. 

The  current  may  now  be  switched  on,  starting  with  all  resistance  in, 
and  gradually  cutting  this  out  until  the  tube  fluoresces  brightly  and  steadily. 
If  the  tube  is  inclined  to  spark  over,  bring  the  regulator  to  within  a 
distance  of  4  or  5  inches  of  the  cathode,  so  as  to  provide  a  kind  of  safety- 
valve  action.  This  will  allow  of  the  sparks  passing  between  the  regulator 
rod  and  the  cathode,  and  tend  to  reduce  the  vacuum  of  the  tube  and  so  avoid 
the  tube  becoming  punctured. 

Before  deciding  that  a  tube  needs  regulation,  allow  it  to  run  for  a  minute 
or  two  to  give  it  an  opportunity  of  finding  its  balance.     Often  it  will  be  found 


Pig. 


39. — Connection  of  the  X-ray  tubes  to  coil. 
Valve  tube  on  positive  pole. 


44  RADIOGRAPHY 

tliat  a  tube  so  treated  will  settle  down  after  a  sliort  run.  In  other  words, 
do  not  be  in  too  great  a  burry  to  regulate  tbe  tube.  A  little  more  or  a  little 
less  current  passing  for  a  short  time  may  successfully  regulate  the  vacuum 
and  allow  of  good  work  beiag  done. 

If  regulation  is  necessary,  proceed  to  adjust  the  regulating  rod  at  a 
distance  which  will  allow  sparks  to  pass  between  the  rod  and  the  cathode 
until  the  tube  works  smoothly,  and  then  remove  the  regulating  rod  away 
from  the  cathode  and  test  the  tube  again. 

Hardening  the  tube  can  only  be  satisfactorily  done  by  gradually  working 
a  soft  tube  up  through  using  it  for  very  light  work  or  for  light  treatment 
untU  it  attains  the  necessary  degree  of  hardness.  Hardening  by  means 
of  reversing  the  current  is  a  method  which  should  never  be  resorted  to. 
When  a  tube  becomes  hopelessly  soft,  the  only  satisfactory  thing  to  do 
is  to  have  it  re-exhausted. 

When  work  is  finished,  if  the  tube  is  not  kept  permanently  in  position, 
it  should  be  removed  from  its  shield  with  great  care,  particularly  while 
warm.  If  possible,  it  should  then  be  placed  upon  a  rack  (which  should  be 
padded). 

Description  of  Methods  used  for  Regrenepation  of  the  Vacuum 
of  the  X-Ray  Tuhe. — All  tubes  (excepting  those  of  very  simple  construc- 
tion), are  fitted  with  a  device  for  lowering  at  will  the  vacuum  or  internal 
resistance  of  the  tube.  The  proA^sion  of  this  regulator  materially  increases 
the  life  of  the  tube.  It  should,  however,  be  always  borne  in  mind  that 
regulation  is  to  be  regarded  as  the  ultimate  process,  and  not  as  an  incidental 
to  the  working  of  the  tube. 

The  number  and  variety  of  the  regulators  of  X-ray  tubes  is  a  striking 
demonstration  of  the  fact  that  the  perfect  regulator  has  yet  to  be  introduced. 
Most  of  the  present-day  regulators  are  efficient  up  to  a  certain  point.  A  few 
of  the  most  commonly  used  will  be  described. 

The  Mica  Regulator. — This  consists  of  a  small  auxiliary  chamber,  in 
which  is  placed  an  electrode  supporting  a  series  of  discs  of  mica.  Facing 
the  discs  is  a  small  metal  knob  which  has  no  utility  other  than  that  of  pre- 
venting a  possible  puncture  of  the  tube,  while  regulation  is  taking  place. 
Attached  by  a  hinged  cap  to  the  mica  electrode  is  a  wire  which  ma}''  be 
brought  into  contact  with  the  cathode  terminal  of  the  tube. 

The  method  of  lowering  the  vacuum  of  the  tube  is  as  follows  :  The 
jointed  arm,  E  F,  is  moved  (by  means  of  a  piece  of  wood,  glass,  or  other 
non-conducting  substance)  towards  B  for  a  few  seconds,  whilst  current  is 
passing  through  the  tube,  when  sparks  should  pass  between  F  and  B. 
The  passage  of  the  current  between  the  latter  two  points  (as  shown  by 
the  sparking)  results  in  the  partial  suspension  of  the  current  from  its 
normal  path  ;  and  during  the  flow  of  the  current  through  the  electrode  in 
the  auxiliary  tube,  a  small  quantity  of  gas  is  liberated,  with  the  con- 
sequence that  a  reduction  in  the  vacuum  takes  place.  When  this  has  been 
achieved  the  sparking  will  automatically  cease,  the  resistance  of  the  tube 
itself  having  become  less  than  that  of  the  gap  F  B.      The  wire  F  should 


THE  regenp:ration  of  the  vacuum 


45 


now  be  thrown  well  back,  and  the  tube  run  cautiously  for  the  first  few 
minutes  after  regulation. 

The  regulation  of  the  tube  during  use  may  be  made  automatic,  if  desired, 
by  placing  the  wire  F  at  such  a  distance  from  B  that  sparking  (with  conse- 
quent regulation)  takes  place  whenever  a  certain  degree  of  vacuum  is  attained. 
This  distance  may  easily  be  determined  by  experiment  with  the  individual 
tube  in  use. 

In  the  case  of  a  tube  which  fails  to  regulate  by  the  above  method,  it  is 
permissible  to  remove  the  lead  from  the  cathode  and  attach  it  to  the  loop  E. 
The  current  should  now  be  passed  with  extreme  caution,  the  pressure 
being  very  carefully  increased  until  the  gas  is  expelled  from  the  mica. 

In  order  to  appreciate  the  degree  to  which  regulation  is  taking  place, 
the  mica  disc  should  be  carefully  watched  while  the  shunt  circuit  is  established. 
It  will  be  seen  that  the  mica  shows  little  flecks  of  red  here  and  there,  and  when 
these  appear,  it  is  a  sign  that  gas  is  being  expelled.     The  time  during  which 


Fig.  40. — Mica  regulator.     (C.  Andrews.) 

A,  Anti-cathode.  C,   Mica  disc.  H 

B,  Cathode.  D,  Carbon.  F 


Wire, 


the  current  should  be  passed  through  the  regulator  depends  obviously  upon 
the  degree  of  hardness  of  the  tube,  and  the  amount  of  softening  which  it  is 
desired  to  attain ;  but  in  any  case  it  is  wiser  to  switch  of!  the  current  as 
soon  as  the  fiery  appearance  is  seen  in  the  mica,  swing  back  the  regulator 
wire,  and  test  the  tube  ;  and  then  to  repeat  the  process  of  regulation  if 
necessary. 

The  regulator  shown  is  merely  a  variation  of  the  standard  mica  pattern, 
and  is  fitted  to  some  smaller  tubes  on  account  of  its  greater  convenience 
where  a  125-mm.  bulb  is  employed.  The  mechanism  is  the  same,  but  in 
place  of  the  hinged  wire,  a  shaped  wire  is  fitted  on  a  spring  and  pin  bearing. 
Normally  this  wire  rests  in  the  position  illustrated.  To  effect  the  softening, 
the  wire  is  tilted  with  a  piece  of  glass  or  wood  until  F  B  are  in  contact,  when 
the  eiiusion  of  gas  from  the  mica  takes  place. 

Larger  models  are  fitted  usually  with  a  double  regulator,  namely  carbon 
and  mica. 

This  consists  of  a  chamber  exactly  similar  to  that  described  above, 
excepting  that,  in  place  of  the  small  metal  knob,  there  is  fitted  an  electrode 
carrying  a  cylinder  of  carbon.     This  is  capable  of  giving  off  gas  in  exactly 


46 


KADIOGKAPHY 


the  same  way  as  does  the  mica  disc  ;  and  so,  in  this  double  regulator,  one  has 
two  supplies  of  gas  upon  which  to  draw.  By  means  of  a  thumbscrew  the 
regulator  wire  can  be  changed  from  one  side  of  the  regulator  to  the  other, 
so  that  when  one  source  of  gas  is  exhausted,  the  second  may  be  brought  into 
use.  The  carbon  regulator  is  operated  in  the  same  way  as  the  mica,  but  it 
should  be  noted  that  there  is  no  "  fiery  "  appearance  with  the  former,  and 
also  that  the  carbon  works  rather  more  freely  than  the  mica.  Care  should 
therefore  be  exercised  in  order  to  avoid  over-regulation. 

In  the  ordinary  way,  a  current  of  1  or  1^  milliamperes  will  cause  the 
standard  regulator  to  work  in  a  few  seconds,  but  in  some  cases,  and  especially 
when  the  regulator  has  been  much  used,  a  greater  current  may  be  necessary 
in  order  to  heat  the  carbon  or  mica  sufficiently.  Experience  will  demonstrate 
this.  The  gases  which  are  supplied  by  it  to  the  tube  allow  the  latter  to 
remain  constant  and  steady. 

The  regenerating  arrangement  with  which  some  tubes  are  provided,  is 
constructed  on  the  principle  of  osmosis.  The  metals  of  the  platinum  group, 
especially  palladium,  have  the  peculiarity  that  they  allow  hydrogen  to  pass 
while  incandescent.  A  tube  of  palladium,  closed  at  one  end  and  open  at 
the  other,  is  sealed  into  the  neck  of  the  tube.  To  protect  it  against 
accidental  damage  it  is  covered  with  a  test  tube,  which  can  be  taken  ofE. 
When  the  tube  has  become  too  hard,  remove  the  test  tube  and  apply  a 
spirit  flame  for  a  few  seconds  to  the  palladium  tube  till  it  is  dark  red. 
The  hydrogen  contained  in  the  spirit  flame  penetrates  into  the  inside  of 
the  tube,  and  makes  the  tube  softer.  The  flame  must  not  be  brought 
near  the  point  where  the  metal  is  sealed  with  the  glass. 

After  the  tube  has  been  regenerated  time  should  be  allowed  for  com- 
plete coohng  before  it  is  used  again.  It  is  advisable  to  bring  the  tube  to  the 
desired  degree  of  softness  each  time  before  it  is  used,  and  only  to  heat  the 
extreme  end  of  the  palladium  tube. 

The   Bauer  Air-Valve   Regulator. — Another  form  of  regulator  is  the 


Fig.  41. — Bauer  air-valve.      (Favre.l 


air-valve  invented   by  Mr.  Heiaz  Bauer.      This   consists  of  a  delicately- 
constructed  valve,  closed  by  a  column  of  mercury,  and  fitted  with  an  air 


METHOD  OF  USING  GUNDELACH  REGULATOR  47 

filter.  By  means  of  a  small  Kand  pump  and  an  india-rubber  tube,  the 
column  of  mercury  is  depressed  so  as  to  open  a  very  small  aperture,  through 
which  a  minute  quantity  of  air  is  thus  allowed  to  pass.  The  mercury  rises 
almost  immediately,  and  the  opening  is  again  sealed,  the  vacuum  of 
the  tube  having  meanwhile  been  lowered  by  the  admission  of  the  air.  If 
desired,  the  Bauer  valve  may  be  worked  with  a  long  rubber  tube,  thus 
allowing  of  regulation  taking  place  from  a  distance,  and  while  the  tube  is 
actually  running. 

Gundelach  Regulator. — Another  very  good  regeneration  apparatus  may 
be  described. 

This  arrangement  consists  of  a  little  condenser  which  is  made  in  the  form 
of  a  cylindrical  glass  tube  covered  with  an  imperfect  conductor  of  electricity. 
By  special  treatment  this  conductor  is  made  to  absorb  a  large  quantity  of 
gas.  It  is  then  covered  with  a  second  glass  tube,  and  both  cylindrical  glass 
tubes  are  so  treated  that  they  cannot  be  pierced  by  a  spark. 


'^    I  >  -    » 


Fig.  42. — Gundelach  tube  with,  regenerator.     (Siemens.) 
a,  wire.  b,  wire.  c,  metal  cap.  d,  metal  cap. 

When  the  tube  has  become  too  hard,  put  the  wire  6  of  the  regenerat- 
ing arrangement  in  contact  with  the  metal  cap  d  of  the  tube.  The  other 
wire  a  has  to  be  so  far  from  the  metal  cap  c  that  a  shunt-spark  passes. 
This  shunt-spark  should  be  half  as  long  as  the  equivalent  spark  of  the 
Rontgen  tube  after  regeneration,  because  the  resistance  of  this  regenerating 
arrangement  is  considerable.  The  current  produces  some  gas  from  the 
substance  of  the  regenerating  arrangement,  and  after  a  few  minutes  the  tube 
will  again  fluoresce  regularly.  The  regeneration,  however,  is  only  completed 
when  the  shunt-sparks  have  ceased  to  pass.  After  regeneration  turn  back 
both  wires.  This  new  regulator  will  work  easily  even  when  the  resistance 
of  the  tube  has  become  so  great  that  no  electric  current  will  pass  through 
the  Rontgen  tube. 

This  arrangement  has  the  great  advantage  that  owing  to  the  two  con- 
ductors being  separated  by  a  glass  tube,  the  gas  is  set  free  uniformly  from 


48  RADIOGKAPHY 

all  parts  of  the  conductors,  and  the  whole  of  the  gas  contained  therein, 
which  is  considerable,  can  be  utilised. 

In  order  to  obtain  good  pictures  it  is  generally  necessary  to  regulate 
the  hardness  of  a  tube  each  time  previous  to  using  it,  and  the  tube  should 
be  adjusted  for  a  medium  hardness ;  and  this  should  be  done  by  means 
of  the  regenerator. 


Suppression  of  Reverse  (Inverse)  Current 

The  reverse  current  is  obviously  a  great  inconvenience  and  must  be  got 
rid  of  if  good  negatives  are  to  be  obtained.  It  is  possible  to  keep  it  down 
to  a  minimum  by  using  a  low  voltage,  a  high  self-induction,  and  a  low 
frequency  in  the  primary  coil,  but  if  intense  discharges  are  required  we  cannot 
suppress  it  entirely  in  this  way,  and  other  means  must  be  adopted. 

Valve  tubes  or  spark-gaps  are  frequently  connected  in  series  with  the 
X-ray  tubes. 

In  a  Spark-gap  the  current  can  discharge  easily  between  a  point  and  a 
plate  if  the  point  is  the  positive  pole,  but  it  does  not  do  so  if  the  point  is 
the  negative  pole.     It  is  possible,  then,  to  create  an  impediment  or  resistance 


Fig.  43. — Spark-gap.     (Siemens.) 

to  the  cm-rent  in  one  direction  only,  whereas  the  passage  is  left  free  in 
the  other. 

There  are  many  types  of  Valve  tubes,  the  most  commonly  used  being 
the  single  valve  tube,  but  the  triple  valve  tube  is  also  used. 

The  nature  of  reverse  current  has  already  been  explained.  In  all 
coil  outfits  this  has  to  be  checked.  It  is  possible  by  a  careful  adjustment 
of  primary  current,  interrupter,  and  tube,  to  cut  this  down  to  a  minimum, 
but  the  slightest  disturbance  of  these  factors  gives  rise  at  once  to  a  percentage 
of  inverse  current,  which,  if  allowed  to  remain,  has  a  deleterious  efiect  upon 
the  tube  and  tends  to  harden  it.  Should  it  become  very  hard  the  persistence 
of  inverse  current  with  strong  currents  in  the  primary  leads  to  damage  of 
the  tube  ;  sparking  takes  place,  and  the  tube  is  punctured. 

It  is  generally  appreciated  that  the  current  which  is  utilised  in  the  pro- 
duction of  X-rays  is  that  which  is  passing  when  the  current  is  breaking,  e.g. 
when  the  magnetic  field  is  at  the  point  of  collapse,  and  it  is  the  endeavour 
to  obtain  a  maximum  tension  at  the  moment,  and  to  relieve  or  "  break  " 
such  tension  with  sufiicient  speed  and  completeness,  that  gives  rise  to  the 
constant  alterations  and  improvements — ^real  or  fancied — in  modern  medical 
electrical  apparatus.     The  more  complete  the  saturation  of  the  induction 


ACTION   OF  REVERSE  CURRENT   ON  X-RAY  TUBE        49 

coil,  and  the  more  suddenly  the  saturation  can  be  "  vented,"  as  it  were, 
through  the  secondary  circuit,  the  more  efl&cient  (other  factors  being  equal) 
the  phenomenon  of  the  Rontgen  rays  produced. 

On  the  other  hand,  the  current  which  is  passing  when  the  current  is 
"  making,"  e.g.  when  the  cycle  of  the  magnetic  field  is  first  commencing 
in  the  primary  of  the  coil,  is  flowing  in  a  reverse  sense  to  that  of  the  current 
at  "  break  "  :  and  it  can  therefore  be  seen  that  if  this  current  Ls  allowed  to 
flow  through  the  X-ray  tube,  it  cancels,  as  it  were,  a  portion  of  the  "  break- 
ing "  pressure  equal  to  its  own.  Now,  the  result  of  this  is  not  only  a  loss 
of  efiiciency  in  that  it  is  a  loss  of  working  current.  The  effects  are, 
unfortunately,  more  far  reaching  than  that,  the  X-ray  tube  becoming 
irretrievably  damaged.  In  the  first  place,  the  actual  passage  of  current  in 
the  "  reverse  "  direction  through  the  tube  means  that  the  anti-cathode,  or 
positive  pole  of  the  tube,  becomes,  for  an  instant,  cathode,  and  vice  versa. 
Now,  it  is  an  estabhshed  fact  that  the  cathode  electrode  breaks  up  much 
more  freely  and  quickly  than  the  anti-cathode,  and  for  this  reason  the 
cathode  is  always  made  from  aluminium,  which  is  less  destructible  in  this 
sense  than  any  other  metal.  But  if  the  cuirent  is  reversed,  and  the 
'"'  cathode  "  is,  for  the  moment,  the  copper  "anti-cathode,"  the  destruction 
is  much  more  rapid,  and  particles  of  metal  are  torn  ofi  from  the  surface. 

The  fragments  of  copper,  tungsten,  etc.,  thus  detached  are  projected 
with  enormous  rapidity  towards  the  wall  of  the  tube,  to  which  they  adhere, 
forming  a  thin  metallic  coating,  particularly  on  the  back  zone  of  the  bulb 
{e.g.  behind  and  above  the  plane  of  the  surface  of  the  target).  The  result 
of  this  coating  of  metal  is  to  absorb  all  the  free  gas  in  the  tube,  and  is  the 
explanation  of  an  old  blackened  tube  remaining  often  dead  hard,  however 
much  it  may  be  regulated  or  re-exhausted.  The  blackening  described  above 
must  not  be  confused  with  the  violet  coloration  in  front  of  the  plane  of 
the  target,  which  latter  is  a  normal  condition  in  all  tubes  after  use,  and 
which  is  free  from  objection. 

The  second  ill-effect  is  that  of  overheating.  If  the  usual  form  of  milli- 
amperemeter,  known  as  the  "  moving  coil "  type,  be  employed,  its  reading 
is  that  of  the  difference  between  the  "  correct "  and  "  reverse  "  currents. 
For  example,  supposing  the  current  in  the  right  direction  to  be  equal  to 
2  milliamperes,  and  that  in  the  wrong  or  reverse  direction  to  be  equal  to 
1  milliampere,  the  milHamperemeter  would  indicate  1  milliampere.  But 
although  this  would  be  accurate  so  far  as  the  measuring  of  the  current  itseK 
went,  it  must  be  remembered  that  the  heating  efiect  of  an  electrical  current 
increases  as  the  square  of  the  amperage.  So  that,  although  the  operator  may 
say,  "  The  tube  is  all  right ;  it  is  taking  only  1  milliampere,"  we  are  subject- 
ing it  to  the  strain  of  3  milliamperes  so  far  as  heat  is  concerned,  e.g.  nine 
times  the  heat  of  a  real  1  milliampere  current.  As  has  already  been  pointed 
out,  it  is  mainly  the  heat  which  destroys  the  balance  of  the  vacuum  of 
the  X-ray  tube. 

It  is  admittedly  a  very  difiicult  matter  to  construct  a  modern  installation 
which  shall  be  free  from  reverse  current,  particularly  as  with  the  higher 

4 


50 


RADIOGRAPHY 


amperage  which  is  demanded  for  rapid  work,  high  voltages  must  also  be 
employed,  and  the  greater  the  voltage  the  greater  the  reverse  discharge. 
The  only  means,  therefore,  of  combating  the  evil  is  to  introduce  some  device 
which  shall  "  rectify  "  the  discharge,  e.g.  eliminate  the  reverse  current  while 
interfering  with  the  proper  current  as  little  as  possible. 

In  order  to  effect  this,  many  contrivances  have  been  tried,  notably  a 
simple  "  spark-gap  "  and  various  forms  of  mechanical  rectifiers.  The  most 
usual  and  most  efBicient  method  is,  however,  the  valve  tube,  a  vacuum 
tube  which  permits  the  current  to  pass  unobstructed  in  the  right  direction 
but  which  should  suppress  absolutely  the  reverse  or  making  current. 

Single  Valve  Tube. — This  valve  tube,  owing  to  its  special  construction, 
is  much  less  inclined  to  become  hard  than  the  simpler  types  of  valve  tubes. 
It  is,  however,  fitted  with  the  new  regenerator  so  that  it  can  be  maintained 
at  a  uniform  degree  of  softness  ;  this  should  be  maintained  at  about  16  mm. 
equivalent  spark-gap.  When  the  tube  requires  regenerating  one  wire  should 
be  connected  to  the  anode  cap  (positive),  and  the  other  held  at  a  distance 
of  about  5  mm.  from  the  cathode  cap  (negative).  As  soon  as  the  tube  shows 
a  white  foggy  light  the  regeneration  is  finished. 


m. 


)^-*^ 


Fig.  44. — Single  valve  tube.     (C.  Andrews. 


Fig.  45. — Trii:)le  valve  tube.     (C.  Andrews.) 


Formerly  when  it  was  desired  to  rectify  on  higher  voltages,  or  while 
using  heavy  currents,  two  or  more  valves  were  placed  in  series;  but  a  difficulty 
then  arose  by  reason  of  the  fact  that  such  valves  did  not  always  increase 
in  hardness  to  the  same  degree,  and  it  was  therefore  almost  impossible  to 
maintain  an  efficient  rectification,  and,  at  the  same  time,  to  pass  the  full 
amount  of  current  needed.  In  order  to  overcome  this  trouble  a  "  double  " 
valve  was  designed,  consisting  of  two  bulbs  and  sets  of  electrodes,  each 
exactly  similar  to  one  single  valve,  but  joined  together  in  such  a  manner 
that  one  vacuum  is  common  to  both  chambers.  The  latter  are  then  con- 
nected in  parallel,  and  placed  in  series  with  the  X-ray  tube,  the  result  being 
that  the  backward  resistance  is  doubled,  the  current  flowing  between  the 
two  sets  of  electrodes.  With  such  a  double  valve,  complete  rectification 
on  voltages  up  to,  say,  200  is  obtainable. 

The  Triple  Valve  is  constructed  similarly  to  the  foregoing,  but  has  three 


VALVE  TUBE8 


51 


intercommunicating  chambers,  and  is  intended  for  use  on  the  highest 
voltages  and  for  the  heaviest  discharges. 

Valve  tubes  may  be  had  either  of  clear  glass,  of  blue,  or  of  a  deep  amber 
colour.  The  latter  is  preferred  by  many  workers,  as  the  colouring  serves 
to  disguise  the  fluorescence,  and  thus  permits  of  a  better  judgment  of  the 
condition  of  the  Eontgen  tube  itself. 

High-tension  Rectifier. — A  different  form  of  valve  is  that  known  as  the 
high-tension  rectifier.  It  consists  of  a  long  aluminium  f mmel  and  a  curved 
mirror,  the  bulb  being  spherical,  and  of  a  diameter  of  approximately  18  cm. 
This  form  of  valve  is  very  efficient,  even  on  high  voltages,  but  it  has  a  ten- 
dency to  increase  in  vacuum  somewhat  rapidly.  For  this  latter  reason  an 
osmosis  regulator  is  provided,  so  that  regulation  is  possible  as  often  as  desired. 

French  Type. — Yet  another  form  is  that  known  as  the  "  French  type," 
which  is  very  similar  to  the  single  valve.  It  has,  however,  in  place  of  the 
plate  anode,  a  thin  pin  with  a  slightly  flattened  head,  and  the  neck  of  the 


Fig.  46. — French  valve.     (C.  Andrews. 


Fig.  47. — Oliver  Lodge  valve  tube.    (Cossar. 


tube  surrounding  this  is  of  much  smaller  diameter  than  in  the  other  cases. 
The  action  of  this  valve  is  very  perfect,  complete  rectification  being  obtained 
without  any  appreciable  loss  of  current.  The  French  pattern  is,  however, 
rather  more  delicate  than  the  others,  and  also  tends  to  go  up  in  vacuum 
rather  quickly.  The  provision  of  an  osmosis  regulator  permits,  however, 
of  the  latter  trouble  being  overcome. 

The  Oliver  Lodge  valve  tube  is  often  used.  It  has  the  disadvantage  that 
it  cannot  be  regulated,  but  it  is  claimed  for  it  that  it  does  not  require  regula- 
tion. This  claim  is  open  to  question.  When  it  is  necessary  to  check  the 
reverse  current  which  is  found  when  very  heavy  discharges  pass  through 
a  tube  a  number  of  these  valve  tubes  may  be  placed  in  the  circuit. 

Regulation  of  the  Valve  Tubes. — The  regulation  of  valve  tubes  is 
efiected  in  a  similar  way  to  that  of  X-ray  tubes,  according  to  the  type  of  regu- 
lator in  use.  In  the  case  of  the  mica  or  carbon  patterns,  the  lead  which  is 
normally  attached  to  the  plate  (anode),  should  be  attached  to  the  ring  of  the 
regulator,  and  current  passed  until  the  blue  appearance  has  been  restored  to 
the  valve  tube.     The  lead  must  then  be  reconnected  to  the  anode  terminal. 


52  RADIOGRAPHY 

Valve  tubes  should  never  be  worked  "hard."  An  intermediate  vacuum, 
giving  a  Geissler  discharge  in  the  body  of  the  tube,  with  a  slight  apple-green 
tint  round  the  spiral  base,  will  be  found  best.  Do  not  forget  also,  that  a 
'■'  hard  "  valve  tube  may  be  emitting  an  appreciable  quantity  of  Rontgen 
rays,  with  a  consequent  need  of  protection  for  the  operator. 


,0=€t 


\ 


Fig.  48. — Gundelach  valve  tube.     (Siemens.) 

Bauer  Air-valve. — The  latest  improvement  in  the  valve  tube  is  the  intro- 
duction of  a  Bauer  air-valve  for  the  regulation  of  the  vacuum.  This  is 
very  useful  and  easily  handled  by  the  use  of  a  small  hand-pump,  a  long 
rubber  tube  allowing  of  regulation  from  a  distance. 

When  intensive  currents  are  used  it  may  be  necessary  to  put  a  valve 
tube  on  each  pole  or  even  to  have  6  or  8  valve  tubes  in  series.  By  using 
valve  tubes  the  amount  of  inverse  current  can  be  practically  abolished  when 
medium  currents  are  employed,  but  when  very  heavy  currents  are  used  it  is 
not  possible,  or  hardly  ever  possible,  to  abohsh  it. 

There  are  several  other  varieties  of  valve  tube  of  more  recent  construc- 
tion. The  various  types  described  are  useful  on  installations  of  medium 
power,  but  if  they  are  used  on  the  more  powerful  installations  of  recent  date, 
they  soon  begin  to  vary  in  hardness,  and  add  considerably  to  the  diflS.culties 
of  the  radiographer.  This  is  particularly  noticeable  when  the  installation  is 
used  alternately  for  short  exposures  and  long  ones.  The  balance  of  the 
valve  tube  is  disturbed,  and  it  will  require  almost  constant  regulation.  It 
should  be  pointed  out  that  when  valve  tubes  are  used  they  require  nearly  as 
much  regulation  as  the  X-ray  tube.  When  the  X-ray  tube  is  known  to  be 
right  and  the  results  are  not  satisfactory,  attention  should  be  paid  to  the 
condition  of  the  valve  tube.  Of  the  more  recent  type  of  valve  tubes  the 
most  efficient  is  one  manufactured  by  the  Polyphos  Company. 

Valve  tubes  from  America  are  promised  which  should  be  a  great 
improvement  on  the  ones  at  present  in  use  in  this  country. 


DETECTION  OF  INVERSE  CURRENT 


53 


Method  of  Detecting-  lleverse  (Inverse)  Current.— A  good  guide 
to  the  presence  of  reverse  current  is  the  appearance  of  the  tube  in  action, 
rings  then  appearing  on  the  aspect  of  the  tube  behind  the  anti-cathode, 
and  the  green  light  in  front  not  being  so  clearly  cut  as  when  there  is  no 
trace  of  reverse  current.     See  frontispiece. 

The  continued  presence  of  reverse  current  leads  to  changes  in  the  con- 
dition of  the  tube.  It  gradually  hardens,  and  the  change  in  its  state  may 
show  itself  in  a  variation  in  the  sounds  produced  when  in  action. 

The  best  method  of  detecting  reverse  current  is  by  the  use  of  an  oscillo- 
scope tube.  The  construction  of  such  a  tube  is  worthy  of  description.  Two 
aluminium  wires,  separated  by  a  small  gap,  are  enclosed  in  an  oblong  glass 


Fig.  49. — Oscilloscope  tul.e.     (Siemens.) 


tube,  and  the  wire  connected  with  the  negative  pole  becomes,  when  the 
current  passes,  surrounded  by  a  violet  fluorescence.  If  the  current  discharges 
in  one  direction,  only  one  of  these  wires  shows  the  violet  light,  but  if  each 
wire  is  alternately  negative  and  positive  both  wires  become  fluorescent  and 
the  length  of  the  fluorescent  band  indicates  the  intensity  of  the  current, 
so  that  we  can  compare  the  relative  strength  of  the  closing  and  breaking 
currents. 

There  are  several  varieties  of  tube  but  the  diagram  illustrates  the 
general  type  in  use. 

The  instrument  is  useful.  It  records 
the  current  passing  in  one  direction 
through  the  tube.  If  reverse  current 
is  present  it  represents  the  difference 
between  the  two  currents.  When  both 
are  equal  then  no  reading  is  recorded. 
If  the  reverse  is  greater  than  the  current 
in  the  right  direction,  then  it  records 
on  the  wrong  side  of  the  zero  mark. 
When  the  oscilloscope  tube  shows 
that  reverse  current  is  present,  then 
valve  tubes  must  be  used  to  check  the 
reverse.  The  combination  of  milliam- 
peremeter,  valve,  and  oscilloscope  tubes 
is  a  most  useful  one,  helping  greatly  to 
regulate  the  exposures. 

The  X-ray  tube  afiords  an  excellent 
indication  of    the    presence    of  reverse 
current.     The  change  in  the  appearance 
of  the  tube  which  has  reverse  current  passing  through  it  is  illustrated  in 
the  coloured  frontispiece. 


Fig.   50. — Oscilloscope  tube  in  action. 
(Schall.) 

a,  The  appearance  of  a  tube  with  the  current 
passing  in  the  right  direction  with  a  trace 
of  reverse  current. 

h.  The  appearance  with  the  current  passing 
in  both  directions  in  almost  equal  pro- 
portions. 


54 


EADIOGKAPHY 


Secondary  Radiations,  Cause,  and  Methods  of  Suppression. — 

Secondary  rays  are  produced  by  the  reverse  current.  All  those  X-rays 
which  do  not  emanate  from  the  focus  of  the  anti-cathode  are  called  secondary 
rays.  They  have  the  same  penetrating  power  as  the  primary  rays  and  are 
plentiful  in  hard  tubes,  but  they  project  the  outlines  of  the  objects  in  other 
directions  than  the  primary  rays,  and  a  loss  of  sharpness  results. 

When  they  are  present  it  is  necessary  to  do  something  to  prevent 
deterioration  of  the  negative.  Secondary  rays  are  also  produced,  or  a 
diffusion  of  the  primaryrays  takes  place  in  the  patient's  body.  It  is  probable 


LCBA  ABCD 

Fig.  51. — Diagrams  showing  the  paths  taken  by  primary  beams  and  secondary  rays.     (Schall.) 

that  both  of  these  manifest  themselves  during  a  long  exposure.  Fig.  51 
shows  the  path  taken  by  the  primary  beam,  and  the  manner  of  projection  of 
secondary  rays  upon  the  photographic  plate. 

The  X-rays,  A  A,  emanating  from  the  focus  of  the  anti-cathode  project 
a  shadow,  B  B,  of  the  object,  0,  on  the  plate.  If  there  were  no  secondary 
rays  this  shadow  would  be  of  uniform  darkness  from  B  to  B,  and  the  space, 
BCD,  would  be  free  from  any  shadow.  But  if  any  current  discharges  in 
the  wrong  direction,  the  so-called  secondary  rays  are  generated  on  the  glass 
of  the  tube.  They  are  indicated  by  the  dotted  hues  h  b.  Although  weaker 
in  intensity,  they  project  shadows,  and  in  another  direction  than  the  primary 
rays  will  do ;  the  shadows  overlap,  and  the  part  between  A  B  will  not  be  so 


SUPPRESSION   OF  SECONDARY  RADIATIONS 


00 


dark  as  that  between  A  A  and  the  space  between  B  C  mil  not  be  as  clear  as 
that  between  C  D.  The  effect  of  the  secondary  rays  is  therefore  to  make  the 
outlines  less  sharp,  and  to  cause  a  general  fogginess.  In  consequence  of  this 
some  details  will  become  indistinct  and  the  finer  ones  will  disappear  entirely. 

In  order  to  minimise  the  effect  of  the  secondary  rays  produced  by 
reverse  currents  upon  the  plate,  diaphragms  are  used.  A  diaphragm  alone 
is  not  sufficient,  and  an  extension  tube  should  also  be  combined  with  the 
diaphragm. 

The  following  illustration  shows  this  method  of  checking  these  ill-effects 
to  some  extent. 

The  illustration  (Fig.  52)  shows  the  primary  or  principal  rays  a  a 
emanating  from  the  anti-cathode  A  ;  the  dotted  Hues  6  h  indicate  secondary 


^    =6 


Fig.   52. — Diagram  showing  the  use  of  a  dia- 
phragm between  tube  and  plate.      (Schall. ) 


Fig.  53. 


-Diagram  showing  the  use  of  a  cylinder 
diaphragm.     (Schall.) 


rays  emanating  from  the  glass  wall  of  the  tube.  If  we  place  a  diaphragm 
between  tube  and  plate,  some  of  these  secondary  rays  are  stopped,  and,  the 
nearer  the  diaphragm  to  the  tube,  and  the  narrower  its  aperture,  the  more 
efficient  will  it  be.  But  as  metal  plates  cannot  be  brought  quite  close  to  the 
tube,  some  secondary  rays  will  still  reach  the  plate  unless  a  cylinder  diaphragm 
is  employed.  Fig.  53  shows  why  a  cylinder  diaphragm  is  bound  to  exclude 
more  secondary  rays  than  a  flat  diaphragm  can  do;  the  cylinder  diaphragm 
can  also  be  used  with  advantage  for  compression. 


Instruments  for  Estimating  the  Hardness  of  the 
X-Ray  Tube. 

The  X-ray  bulb  in  action  presents  a  picture  which  in  itself  is  a  guide 
to  the  condition  of  the  tubes  as  regards  hardness,  presence  of  inverse  current, 
and  radiographic  value,  but  if  good  work  is  to  be  maintained  it  is  necessary 


56 


KADIOGEAPHY 


Fig.  54. — Adjustable  spintermeter. 
(Watson.) 


to  be  able  to  record  the  actual  conditions  under  which  a  particular  standard 

has  been  attained.     When  this  has  been  done  it  should  be  possible  to  repro- 
duce the  condition  of  tube  necessary  at  any  time. 

There  are  several  methods  for  estimating  the  degree  of  vacuum  (or 

hardness)  of  the  X-ray  tube.     These  are  (a)  measurement  of  the  alternate 

spark-gap,  (6)  the  Bauer  QuaUmeter,  (c)  radiometers  :  (1)  Walter,  (2)  Walter- 

Benoist,  (3)  Wehnelt  crypto- 
radiometer,  (4)  measurement  by 
the  milhamperemeter. 

A  rough  though  practical 
method  of  estimating  the  inter- 
nal resistance  of  the  X-ray  bulb 
consists  of  the  Spintermeter, 
by  means  of  which  the  alternate 
spark-gap  is  measured. 

A  convenient  form  of  spin- 
termeter is  here  shown.  The 
action  is  simple.  The  point  A 
is  withdrawn   to   its  limit,  and 

the  tube  set  in  action.      By  gradually  approximating  the  point  A  to  the 

point  B  a  position  is  reached  when  the  current,  instead  of  passing  through 

the  tube  sparks  between  the  points  A  and  B,  a 

scale  attached  giving  the  distance  in  inches  or 

centimetres.     The  spark-gap  is  measured,  and 

gives  approximately  the  hardness  of  the  X-ray 

bulb.      The  spintermeter  may  be  attached  to 

the  coil,  or  more  conveniently  mounted  on  a 

separate  base,  and  placed  at  some  distance 

from  the  coil. 

The  Bauer  Qualimeter  is  an  instrument 

for  determining  the  degree  of  hardness  of  the 

X-ray  tube.     It  is  useful,  but  not  always  to  be 

relied  upon. 

This  instrument  is  connected  by  a  wire  to 

the  negative  terminal  of  the  coil  or  the  cathode 

of  the  tube.      It  is  a  static  electrometer  and 

condenser  which  indicates  automatically  the 

potential  of  the  cathode,  and  hence  the  quality 

of  the  X-rays.     The  apparatus  consists  of  two 

wings,  which  swing  between  two  fixed  plates. 

Both  wings  and  plates  are  equally  charged,  so 

that    a    repulsion   takes    place    between    them.    Fig.  55.— Bauer  qualimeter.    (Favre. 

The  intensity  of   this  repulsion   is  in  exact 

proportion  to  the  electrical  tension  in  the  secondary  circuit,  and  is  indicated 

by  the  deviation  of  a  pointer  over  a  suitably  divided  scale. 

As  is  well  known,  the  penetration  of  the  X-rays  is  a  function  of  the 


BAUER  QUALIMETER  57 

electrical  potential  in  the  secondary  circuit,  so  that  a  simple  measurement 
of  this  potential  between  the  anode  and  cathode  will  give  as  an  indication 
of  the  hardness  of  the  tube.  The  scale  is  gauged  according  to  the  absorption 
of  the  X-rays  by  sheets  of  lead  of  different  thickness,  increasing  regular 
from  one-tenth  of  a  millimetre  to  one  millimetre. 

No.  1  on  the  scale  denotes  X-rays  of  such  a  hardness  as  to  be  totally 
absorbed  by  J^^J  millimetre  of  lead.  When  the  index  is  at  No.  10  we  know 
that  the  tube  is  giving  out  rays  which  will  penetrate  0-9  millimetre  of  lead, 
but  will  be  totally  absorbed  by  1  milhmetre  of  lead. 

As  already  explained,  the  instrument  is  unipolar,  being  joined  up  by  a 
single  wire  to  some  point  in  electrical  connection  with  the  cathode.  The 
instrument  is  contained  in  an  ebonite  case,  which  swings  freely  from  a  bracket 
on  the  wall  or  a  stand,  so  as  to  be  always  in  a  vertical  position. 

The  following  experiment  will  demonstrate  the  use  of  the  instrument. 
The  tube  is  disconnected,  and  a  current  from  the  generator  is  sent  through 
the  spark-gap.  In  this  case  the  deflection  of  the  qualimeter  becomes  greater 
with  the  increasing  spark-gap,  while  the  reading  of  the  milliamperemeter 
recedes.  The  spark-gap  itself  is  often  used  for  gauging  the  hardness  of  the 
tube.  This  proceeding,  however,  is  not  exact  enough  for  practical  purposes, 
as  the  resistance  of  the  spark-gap  is  dependent  upon  the  form  of  the  electrode 
ball,  point,  or  disc,  and  upon  the  humidity  of  the  atmosphere. 

No  metallic  surface  should  be  allowed  to  be  within  a  distance  of  8  to 
10  inches  from  the  instrument.  The  purposes  for  which  the  qualimeter 
can  be  used  are  the  following  : 

Therapeutics. — ^It  is  becoming  more  and  more  imperative  to  regulate 
the  hardness  of  the  tubes  to  the  various  diseases  treated.  As  modern 
pubhcations  almost  always  give  the  degree  of  hardness  in  qualimeter  degrees, 
it  is  obviously  necessary  to  employ  the  qualimeter  to  obtain  the  same  results. 
The  spark-gap,  which  has  very  generally  been  used  up  till  now,  is  to  be 
rejected  for  the  reasons  mentioned  above.  In  addition  to  this  it  is  possible 
by  the  help  of  the  qualimeter,  to  use  the  so-called  indirect  calculation  of 
the  erythema  dose  instead  of  the  direct  measurement  by  the  Sabouraud 
pastille,  in  cases  where  the  degree  of  hardness  employed  is  always 
approximately  invariable,  as  is  the  case  in  the  treatment  of  the  skin  and 
deeper  tissues. 

The  process  can  be  shortly  described  as  follows  :  Take  a  new  X-ray 
bulb  and  give  an  erythema  dose,  noting  the  reading  of  the  milliamperemeter 
and  the  qualimeter  and  the  time.  The  product  of  these  three  factors — time, 
milliamperemeter,  and  qualimeter  degrees — will  be  always  found  the  same 
for  the  erythema  dose  (under  an  approximately  unvarying  degree  of  hard- 
ness), however  much  the  two  other  factors — intensity  and  time — may  be 
varied.  This  method  has  been  scientifically  proved  by  Klingelfuss  of  Basel. 
A  practical  example  will  serve  to  illustrate  the  above.  If  an  erythema  dose 
has  been  reached  in  ten  minutes  with  a  hardness  of  3  Bauer-degrees  and  an 
intensity  of  4  milliamperes,  the  product  will  be  10  x  3  x  4=120,  If  a  bulb 
is  being  employed  which  registers  3  degrees  of  hardness  with  an  intensity  of 


58  EADIOGRAPHY 

2  milliamperes,  it  will  take  twenty  minutes  to  produce  the  same  result : 
the  product  will  again  be  2  x  3  x  20=120.  For  treatment  of  the  skin  and 
deeper  tissues,  two  different  degrees  of  hardness  are  generally  used  (for 
example,  3  Bauer  and  7  Bauer),  and  the  erythema  dose  need  only  be  calcula- 
tive  once  for  all.  Shght  fluctuations  in  hardness  make  no  difference,  and  if 
they  occur  during  exposure  they  can  be  adjusted  by  regulating  the  primary 
current.  On  the  other  hand,  the  current  employed  must  be  kept  within 
such  bounds  that  the  tube  remains  steady.  Should  the  current  through  the 
tube  be  too  strong  or  too  weak,  more  or  less  current  may  be  passed  through 
the  tube  by  adjusting  the  shunt.  Too  weak  a  current  hardens  the  tube, 
whereas  too  strong  a  current  has  the  opposite  effect. 

For  comparative  scale  of  the  usual  instruments  for  measuring  the 
hardness  of  tubes,  see  page  61. 

Technique  for  Exposures. — The  time  of  exposure  can  be  calculated  in  the 
same  way  as  that  for  an  erythema  dose.  We  first  ascertain  within  what 
time  and  with  what  degree  of  hardness  and  intensity  a  good  Rontgen 
negative  of  any  particular  region  is  obtained.  These  readings  may  be  noted 
on  a  chart  hung  within  the  protective  cabin,  and  in  this  way,  by  using  the 
same  figures,  a  satisfactory  result  can  always  be  obtained,  and  failures 
excluded.  It  is  here  that  the  qualimeter  is  particularly  useful,  since  different 
degrees  of  hardness  are  required  for  the  production  of  good  pictures  of 
various  parts  of  the  body.  If  the  operator  prefers  to  use  one  tube  for  all 
purposes,  he  will  find  the  Bauer  air-valve  tube  most  practical.  With  this 
he  is  able  to  adjust  the  tube  to  any  degree  of  hardness  desired.  For  in- 
stantaneous exposures  the  most  important  point  is  to  adjust  the  hardness 
of  the  tube  so  that  a  sufficient  number  of  hard  rays  may  be  emitted.  To 
ascertain  this,  the  tube  should  be  driven  with  a  normal  intensity  of  2  milli- 
amperes, and  the  hardness  tested  by  the  qualimeter.  From  the  resulting 
negative  it  can  be  immediately  ascertained  whether  the  tube  is  too  high 
or  too  low.  If  the  picture  is  too  faintly  shaded,  the  degree  of  hardness  was 
too  low  ;   if  it  is  too  dark,  the  degree  was  too  high. 

As  the  result  of  considerable  experience  in  the  use  of  this  instrument 
it  may  be  stated  that  the  quahmeter  is  particularly  suited  for  radioscopic 
work,  since  it  indicates  the  hardness  of  the  tube  at  a  distance,  and  without 
the  operator  being  brought  into  dangerous  proximity  to  the  tube  in  order  to 
measure  its  hardness. 

As  has  been  said,  the  qualimeter  has  not  only  created  a  possibility  of 
working  with  greater  exactness,  but — and  to  this  we  again  call  particular 
attention — ^it  is  not  now  necessary  to  come  within  the  dangerous  area  for 
the  purpose  of  ascertaining  the  degree  of  hardness.  Finally,  with  its  help 
the  tubes  can  be  worked  much  more  economically. 

Radiometers. — These  serve  to  determine  accurately  the  degree  of 
hardness  of  the  tubes,  that  is  to  say,  the  penetrability  of  the  rays. 

Walfer^s  Radiometer  consists  of  a  sheet  of  lead  mounted  on  a  wooden 
frame  and  with  eight  circular  holes,  combined  with  an  adjustable  fluorescent 
screen.     The  holes  are  covered  with  platinum  foil  of  a  thickness  varying  in 


RADIOMETERS 


59 


geometrical  progression  from  '•t)05  mm.  for  hole  No.  1  to  '64  mm.  for  hole 
No.  8.  If  the  apparatus  is  placed  in  the  path  of  the  rays  a  certain  number 
of  holes  become  visible  on  the  fluorescent  screen,  the  number  depending  on 
the  hardness  of  the  tube.  The  degree  of  hardness  is  indicated  by  the  largest 
cypher  marked  on  the  visible  holes. 


Fig.  56. — Walter's  radiometer.     (Siemens.) 


The  Walter-Benoist  Radiometer  has  aluminium  apertures  of  various 
thicknesses  and  a  piece  of  silver  foil.  One  of  the  aluminium  apertures  will 
show  the  same  degree  of  brightness  as  the  silver  foil.  The  cypher  on  this 
aperture  indicates  the  hardness  of  the  tube. 


Fig.  57. — Beuoist  radiometer. 
(Siemens. ) 


Fig.  58. — Protected  front 
for  Fig.  57. 


A  simple  form  of  Benoist  radiometer,  with  slots  for  screws,  may  be  fixed 
on  the  fluorescent  screen ;  the  lead  glass  covering  the  latter  protects  the 
operator. 

Wehnelt's  Crypto-Radiometer  is  an  improvement  on  the  foregoing  radio- 
meters. It  is  provided  with  a  wedge-shaped  aluminium  strip,  and  alongside 
this  a  flat  silver  strip,  both  of  which  can  be  moved  by  means  of  a  ratchet  over 
a  brass  plate  provided  with  a  thin  slit.  The  apparatus  is  adjusted  until 
both  strips  show  the  same  degree  of  brightness  on  a  fluorescent  screen.  A 
scale  indicates  the  position  of  the  aluminium  strip,  i.e.  the  penetration  of 
the  tube. 

This  is  a  useful  instrument ;  it  is  efficiently  protected,  and  will  be 


60 


RADIOGRAPHY 


Fig.  59. — Wehnelt's  crypto-radiometer. 
(Siemens.) 


found  to  be  extremely  useful  for  routine  work.  The  radiometer  can  be 
fitted  betdnd  the  lead-lined  screen,  and  a  suitable  tube-holder  attached  to 
the  tube  while  it  is  being  tested.  A  sht  must  be  cut  in  the  lead  linings 
of  the  screen.     Then  the  apparatus  may  be  used  with  safety. 

When  using  these  radiometers,  and  particularly  at  the  present  time 

when  heavy  currents  and  hard  tubes  are 
coming  into  general  use,  it  is  necessary 
to  point  out  that  the  protective  devices 
supphed  with  the  measuring  apparatus 
are  not  nearly  sufficient  for  the  protec- 
tion of  the  operator  if  many  observations 
have  to  be  made  daily.  The  instru- 
ments should  be  mounted  on  a  screen 
lined  with  thick  lead,  and  the  slots  for 
comparing  standards  should  have  thick 
lead  glass. 

The  instruments  described  all  esti- 
mate more  or  less  accurately  the  hard- 
ness of  the  X-ray  bulb.  There  are  also  instruments  which  measure  the  quan- 
tity of  current  actually  passing  to  the  tube.  These  are  useful  in  estimating 
the  exposure  necessary  at  particular  times.  Later,  the  exact  method  of 
combining  all  the  factors  required  for  the  estimation  of  exposure  will  be 
described.  For  our  present  general  purpose  it  is  sufficient  to  state  that  there 
are  instruments  used  to  measure  the  current  passing  through  the  tube,  the 
actual  quantity  of  which  will  vary  with  the  internal  resistance  of  the  tube. 
For  example,  a  soft  tube  will  allow,  say,  10  milliamperes  to  pass,  whilst  with 
the  same  primary  current  a  much  harder  tube  will  only  allow,  say,  1  milli- 
ampere  to  pass. 

Measurement  of  X-Rays  by  Milliampepe- 
meter. — A  milliamperemeter  is  necessary  for 
this'  purpose  when  radiographic  exposures  are 
given,  and  acts  by  estimating  the  quantity  of 
current  passing  through  the  X-ray  tube.  That 
shown  is  a  Deprez-d'Arsonval  moving  coil  in- 
strument, and  it  is  an  advantage  to  have  the  zero 
in  the  centre  of  the  scale  for  measuring  positive 
and  negative  currents.  They  do  not  show  the 
actual  current  traversing  the  X-ray  tubes,  but 
its  mean  value,  which  can,  however,  be  taken  as 
a  relative  measure  of  the  intensity  of  the  rays. 
So  long  as  the  pointer  remains  stationary  this 
indicates  that  the  hardness  of  the  tube  is  con- 
stant. Should  the  tube,  when  in  use,  become 
harder,  the  pointer  will  move  towards  zero.  The  instrument  is  as  a  rule 
specially  constructed  so  that  it  is  impossible  for  sparking  to  occur  inside, 
and  the  pointer  should  be  well  damped.     There  are  other  instruments  for 


Fig.  60. — Milliamperemeter. 
(Siemens.) 


MEASUREMENT  OF  HARDNESS  OF  TUBES 


CI 


measuring  the  quantity  of  X-rays  used  in  dosage.     These  are  described 
more  fully  in  the  section  on  Radio-therapeutics. 

The  table  below  gives  the  comparative  values  of  the  instruments  most 
frequently  used,  namely  :   Bauer,  Wehnelt,  Walter,  and  Benoist. 

Comparative  Scale  of  the  usual  Instruments  for  measuring  the 
Hardness  op  Tubes 

soft  medium  hard 


Bauer  .... 

1 

2 

3         4 

5 

7-5 

6 

7 

8 

9 

10 

Wehnelt 

1-5 

3 

4-5        6 

9 

10-5 

12 

13-5 

15 

Walter 

1 

1-2 

2-3      3-4 

4-5 

5-6    1    6-7        7-8 

Benoist 

1 

2 

3     i     4 

5 

6           7           8 

9 

10 

The  ingenious  method  used  for  the  control  of  the  Coohdge  tube  appears 
to  be  the  perfect  one  for  the  estimation  and  control  of  the  hardness  of  the 
X-ray  given  off  from  the  bulb. 

The  penetrating  power  of  the  X-rays  is  dependent  upon  the  speed  of 
the  cathode  stream,  and  the  latter  is  varied  by  increasing  or  diminishing 
the  potential  at  the  terminals  of  the  tube.  The  provision  of  an  ammeter 
in  the  battery  circuit  gives  the  means  necessary  for  estimating  the  hardness 
of  the  ray.  The  miUiamperemeter  in  the  secondary  circuit  gives  the  current 
passing  through  the  secondary  circuit.  By  using  these  two  indicators 
together  it  is  possible  not  only  to  estimate  but  to  produce  at  mil  a  particular 
and  fairly  constant  type  of  X-ray.  This  not  only  dispenses  with  other  more 
tedious  methods  of  estimation  but  enables  the  operator  to  reproduce  at  any 
time  the  particular  ray  he  may  require. 


TUBE   STANDS,   COUCHES,   COMPRESSORS,   AND 
SCREENING  STANDS 

The  X-Ray  Tube-Stand 

There  are  many  varieties  and  adaptations  of  this  piece  of  apparatus. 
The  chief  essential  is  that  the  shield,  whatever  it  may  consist  of,  should  be 
efficiently  protective,  and  of  a  size  capable  of  holding  easily  the  largest  tube. 
The  clamps  should  have  an  easy  movement,  and  as  little  metal  as  possible 
should  enter  into  the  structure  of  the  shield  and  tube  clamps.  This  is 
particularly  desirable  when  heavy  currents  are  used,  for  otherwise  the  current 
may  spark  from  the  tube  to  the  metal,  and  lead  to  a  marked  diminution  of 
current  passing  through  the  tube  and  to  disappointment  in  results.  The 
tube  is  frequently  punctured  if  these  precautions  are  not  taken. 

There  is  a  type  of  protected  tube-stand  which,  with  some  modifications, 
is  made  by  all  the  principal  manufacturers,  and  its  essential  points  are 
enumerated  below.  Such  a  stand  will  answer  very  well,  not  only  for  thera- 
peutic work,  but  in  small  installations  for  radiography  and  radioscopy.  It 
consists  of  a  wooden  tube-box,  fined  with  protective  rubber,  and  as  some  of 
these  boxes  err  on  the  small  side,  this  is  a  point  that  should  be  noted.  To 
the  front  of  this  box  all  diaphragms,  applicators,  and  pastille-holders  can  be 
fitted.  This  box  is  attached  to  a  horizontal  wooden  arm  by  a  mechanical 
method,  and  this  part  should  be  carefully  examined  to  avoid  subsequent 
disappointment  and  annoyance.  As  the  tube-box  may  have  to  carry  con- 
siderable weight  and  still  be  used  at  all  angles  and  positions,  each  move- 
ment should  be  controlled  by  a  separate  solid  metal  clamp,  and  not  by 
one  that  can  wear  or  compress.  It  is  better  to  pay  a  little  more  for  extra 
work  in  this  direction  than  to  court  disaster  by  some  part  not  holding  well, 
and  perhaps  allowing  the  tube-box  to  drop  in  the  middle  of  an  exposure. 
The  horizontal  wooden  arm  has  a  rack-and-pinion  adjustment,  which  is  fitted 
by  means  of  a  bracket,  with  a  vertical  rack-and-pinion  movement  attached  to 
a  wooden  upright,  which  in  turn  should  be  mounted  on  a  solid  metal  base, 
not  a  wooden  one,  so  as  to  make  a  stable  and  fairly  rigid  apparatus.  All 
adjustments  can  then  be  conveniently  made.  An  elaboration  of  this  is  the 
pillar  tube-stand,  suitable  for  use  with  much  larger  outfits  and  for  all  kinds 
of  work. 

Description  and  Use  of  Pillar  Stands. — The  pillar  stand  (Fig.  61) 
consists  of  a  solid  pedestal  with  castors,  which  carries  a  vertical  column  of 

62 


THE  PILLAR  TUBE -STAND 


G3 


steel  tube.  An  adjustable  sleeve,  to  which  one  end  of  the  wire  is  secured, 
is  mounted  on  this  column.  The  wire  runs  over  a  pulley,  and  carries  a 
movable  lead  weight  inside  the  steel  tube,  which  serves  to  balance  the  tube- 
box  and  the  whole  movable  system.  The  sleeve  can  be  locked  in  any 
position  by  the  lever.  The  pulley  is  secured  to  a  ball-bearing,  and  can 
revolve  freely  round  the  top  of  the  column.     The  sleeve  has  a  horizontal 


Fig.  61. — Pillar  stand,  protected  tube-box  and  accessories.      (Siemens. 


arm,  which  carries  a  second  sleeve.  In  order  to  avoid  a  displacement  of 
the  sleeve  in  the  longitudinal  direction  of  the  arm,  the  latter  has  a  groove 
at  the  end,  which  engages  the  screw  of  the  lever.  The  tube-box  is  hinged 
to  the  sleeve  in  such  a  manner  that  it  may  be  revolved  horizontally  through 
an  angle  of  about  90°.  In  order  to  fix  the  position  of  the  angle,  there  is  a 
circular  slot  above  the  hinge,  through  which  travels  the  screw  of  the  lever. 
If,  now,  the  lever  is  turned  to  the  right,  its  head  is  firmly  pressed  against  the 


64 


EADIOGKAPHY 


slot,  and  thereby  prevents  any  further  rotation  of  the  hinge.  The  sleeve, 
together  with  the  tube-box,  can  be  turned  radially  to  the  arm.  The  sleeve 
is  locked  by  tightening  up  a  screw  by  means  of  the  lever,  so  that  the  sleeve 
is  pressed  on  to  the  arm.  Thus,  the  tube-box  can  be  moved  as  follows  : 
{a)  up  and  down  ;  (6)  round  the  column  ;  (c)  round  the  arm  ;  {d)  through 
an  angle  of  90°  round  any  axis  vertical  to  the  arm,  so  that  this  pillar  stand 
permits  of  adjusting  the  position  of  the  tube  within  the  widest  limits. 

The  tube-box  itself  is  lined  inside  with  lead  rubber  material,  as  a 


Fig.  62. — A  form  of  tube-stand,  which 
combines  many  useful  mechanical  move- 
ments,    (Watson.) 


Fig.  63. — A  convenient  type  of  tube- 
stand  with  iris  diaphragm. 


protection  against  accidental  effects  of  the  rays.  Its  back  forms  a  door. 
The  front  is  provided  with  a  rectangular  opening  of  about  170  x  220  mm., 
in  which  the  accessories  subsequently  to  be  described  are  inserted.  In  order 
to  be  able  conveniently  to  manipulate  the  tube-box  during  adjustment,  it 
is  provided  with  a  handle.  One  of  the  sides  is  fitted  with  an  observation 
window  of  lead  glass,  through  which  the  X-rays  can  only  penetrate  with 
difficulty,  and  this  may  be  closed  by  the  shutter,  when  making  a  fluoro- 
scopic examination.  Two  pieces  of  wo©d  with  slots  are  fitted  to  the  under 
side  of  the  box,  between  which  the  -tube-holder,  together  with  the  tube 


THE  TUBE   STAND 


65 


is  inserted.  The  holder  must  be  secured  to  the  cathode  neck  of  the  tube. 
The  latter  must  be  so  mounted  that  the  anti-cathode  is  turned  towards  the 
front  of  the  box  (with  the  opening  for  the  X-rays),  and  occupies  about  the 
centre  of  the  box.  The  tube-holder  can  be  fixed  by  turning  the  wood  screw 
to  the  right. 

In  order  that  neither  the  operator  nor  the  patient  may  receive  shocks 
due  to  sparks  jumping  from  the  tube  to  any  part  of  the  stand,  a  terminal 
is  mounted  on  the  pedestal,  which  is  connected  ^^^th  all  the  metal 
parts  of  the  stand,  and  also  with  the  accessories,  which  are  inserted  in 
the  front  opening  of  the  box  through  the  metal  strip  which  runs  along 
the  tube-box.     This  terminal  must  be  connected  to  a  water-pipe  by  means 


Fig.  65.- 


FiG.  64. — Tube-box  with  extension  tube. 


-Tube-box  with  rectangular 
diaphragm. 


of  an  insulated  or  bare  wire,  or  to  an  earthed  conductor,  should  this  be  avail- 
able on  the  supply  mains. 

In  order  to  prevent  any  accidental  movement  of  the  stand,  two  screws 
are  provided  in  the  pedestal  by  means  of  which  the  latter  may  be  slightly 
raised,  so  as  to  put  the  two  castors  out  of  gear. 

Accessories. — 1.  A  wooden  Carrier  with  an  opening  (about  170  x  170 
mm.),  which  is  inserted  in  the  front  of  the  tube-box,  and  feed  by  means  of 
the  screw.  In  order  to  centre  the  X-rays,  it  may  be  adjusted  up  and  down 
to  the  extent  of  about  30  mm.  The  accessories  mentioned  subsequently, 
compressor  diaphragm,  iris  diaphragm,  and  holders,  can  be  attached  to  this 
carrier  ;  for  this  purpose  it  is  provided  with  a  small  spring,  which  snaps 
into  a  corresponding  small  slot  in  the  accessories  themselves,  and  thus 
prevents  them  from  falling  out  when  the  tube-box  is  rotated.  The  carrier 
should  be  so  inserted  in  the  box  that  the  spring  is  on  the  same  side  as  the 
screw,  so  that  the  metal  strip  makes  metallic  connection  with  the  strip  on 
the  opposite  side,  and  thereby  the  metal  parts  of  the  carrier,  as  well  as  of  the 
accessories  which  it  carries,  are  earthed, 

2.  The  Compressor  Diaphragm,  of  about  140  mm.  long  by  125  mm. 
diameter,  which  serves,  like  the  compressor  diaphragm  of  Professor  Dr. 
Albers-Schonberg,  to  produce  radiographs  with  good  contrasts,  this  being 

5 


66  KADIOGRAPHY 

attained  primarily  by  screening  the  rays  not  required,   and    partly  by 
efficiently  fixing  or  compressing  the  patient. 

3.  An  Iris  Diaphragm,  which  must  be  inserted  in  the  carrier  in  such  a 
manner  that  the  spring  snaps  into  the  slot.  The  largest  diameter  of  the 
opening  is  about  105  mm.  and  the  smallest  about  25  mm. 

4.  A  Holder,  which  must  be  inserted  in  the  wood  carrier,  and  is  intended 
for  holding  the  three  diaphragms  as  well  as  the  centering  device.  This 
holder  must  also  be  inserted  in  such  a  manner  that  the  spring  snaps  into 
the  corresponding  slot.  A  Holder  for  the  lead-glass  tubes,  or  applicators, 
which  must  also  be  inserted  in  the  wood  carrier.  The  tubes  can  be  fixed 
by  turning  a  wooden  screw. 

5.  Four  Lead  Glass  Tubes,  of  100  mm.  length,  with  diameters  of  about 
18,  40,  50,  and  75  mm.  respectively.  The  largest  tube  is  conical,  and  should 
be  inserted  into  the  carrier  at  its  widest  end. 

6.  A  Centering  Device,  which  consists  of  a  small  metal  tube  attached 
to  a  circular  plate,  to  the  free  end  of  which  a  small  circular  screen  of 
barium  platino  cyanide  is  attached.  The  centering  device  must  be  inserted 
in  the  holder.  In  order  to  centre  the  tube,  the  latter  is  switched  on, 
and  the  wood  carrier  with  the  centering  device  is  moved  until  the  small 
fluorescent  screen  is  in  a  state  of  complete  fluorescence,  that  is,  until 
it  shows  a  complete  circle  and  not  only  a  part  of  the  circle.  Centering  can 
also  be  well  effected  without  the  tube  being  switched  on,  by  removing  the 
cap  and  the  little  screen  from  the  centering  tube,  and  observing  the  anti- 
cathode  through  the  latter,  and  then  adjusting  the  tube  until  the  centre  of 
the  anti-cathode  is  observed. 

7.  A  Shutter  Diaphragm,  the  aperture  of  which  can  be  variably  adjusted 
by  means  of  levers,  in  the  form  of  a  rectangle.  The  largest  aperture 
is  120  X  120  mm. 

8.  Holders  for  the  Tubes. — In  order  to  avoid  the  unnecessary  removal 
of  the  tube-holder  from  the  tube,  when  another  tube  is  employed,  extra 
tube-holders  are  recommended,  so  that  with  this  arrangement  the  tubes 
are  always  centered  when  they  have  once  been  adjusted. 

9.  A  Pastille  Holder. — This  can  be  inserted  in  an  opening  in  the  base 
of  the  box,  and  is  provided  with  a  circular  slot,  in  which  the  re-agents 
of  the  Saboraud  and  Noire  radiometers  are  inserted.  By  turning  the  metal 
piece  the  re-agents  are  prevented  from  falling  out. 

Instructions  for  Use. — The  stand  is  earthed,  as  already  described,  by 
connecting  the  terminal  by  means  of  a  wire  with  gas  or  water  pipe, 
or  possibly  with  the  neutral  wire  of  the  supply  mains.  When  moving  the 
tube-box,  the  handle  can  always  be  held  with  one  hand.  In  order  to 
adjust  the  box,  it  should  be  brought  to  the  desired  position  by  loosening  the 
lever,  and  then  fixed  rigidly  at  once  by  means  of  the  same  lever.  This 
lever  when  loosened  should  only  be  turned  so  far  as  to  enable  the  box  to  be 
easily  revolved.  Then  the  box  can  be  turned  into  the  desired  position 
round  the  arm,  and  &Ked  again  by  means  of  a  lever.  Finally,  the  box  is 
raised  to  the  desired  height,  and  if  necessary  rotated  round  the  colunm, 


THE  X-RAY  COUCH  67 

and  then  tightened  up  again  by  means  of  the  lever  provided.  Care 
should  always  be  taken  that  the  fixing  screw  for  the  tube-carrier  is  well 
tightened  up,  so  that  the  wood  carrier  does  not  fall  out  when  turning  the 
box.  Should  it  be  desired  to  apply  fluoroscopy  or  radiography  to  thick 
parts  of  the  body,  the  wood  carrier  front  may  be  completely  removed. 


Couches  and  Stands 

A  simple  couch  will  suffice  for  a  small  installation.  In  large  institu- 
tions, where  a  considerable  amount  of  work  has  to  be  got  through  quickly, 
a  couchi  with  mechanical  contrivances  is  necessarv.     The  couch  should  be 


Fig.  66. — A  eouvenieut  form  of  X-ray  couch.      (Siemens.) 

jPitted  with  a  protected  tube-box,  the  top  of  the  table  is  so  constructed  that  the  patient  may  be 
moved  in  several  directions  to  facilitate  centering  of  parts  of  the  body  over  the  X-ray  tube. 

sufficiently  protected,  and  should  have  conveniences  for  working  with  the 
tube  below  the  table.     When  possible  overhead  work  should  be  undertaken. 

Tfiis  compressor  is  a  most  important  piece  of  apparatus,  mounted 
upon  a  suitable  table  with  adjustments  and  tube-carriers,  and  is  a  great  help 
tto  the  radiographer,  since  it  facilitates  the  work  and  saves  time  if  the  adjust- 
anents  are  easily  worked.  There  are  many  forms  to  select  from,  and  a  great 
deal  must  be  left  to  the  individual  worker. 

The  Albers-Schonherg  Compressor  is  the  best-known  pattern,  and  such 
a  compressor  apparatus  has  become  an  absolutely  essential  auxiliary  for 
radiography.  The  chief  advantages  which  are  guaranteed  to  the  radio- 
grapher by  its  proper  use  may  be  briefly  summarised  as  follows  : 

1.  By  means  of  the  compressor  diaphragm  the  secondary  rays  which 
affect  the  value  of  the  radiograph  can  be  screened  completely. 

2.  The  parts  under  examination  can  be  kept  absolutely  at  rest,  so  that 


68 


RADIOGKAPHY 


Fig.  67.— Albers-Sclionberg  compressor.     (Siemens.) 


Fig.  68. — A  couch  fitted  with  protected  tube-box  underneath.      (Butt.) 

This  has  movements  in  three  directions,  and  is  arranged  for  stereoscopic  work.  Au  upright 
attached  to  the  box  carries  a  horizontal  arm  to  which  is  fitted  a  plumb-line  to  indicate  the 
exact  position  of  the  anti-cathode  of  the  tube.  On  the  upper  aspect  of  the  couch  a  movable  tube- 
holder  is  fitted.  This  has  attached  to  it  a  compression  diaphragm.  It  is  also  arranged  for 
the  taking  of  stereoscoj^ic  negatives. 


ON  THE   USE   OF  THE  COMPRESSOR  69 

want  of  sharpness,  due  to  voluntary  or  involuntary  movement,  to  respiration 
or  pulsation  of  the  heart,  is  eliminated. 

3.  All  parts  of  the  human  body  can  be  radiographed,  so  that  the  com- 
pressor apparatus  can  be  employed  for  all  exposures  required,  \\^th  the 
exception  of  general  exposures  over  a  large  area  of  the  body. 

It  is  now  generally  recognised  that  a  certain  quantity  of  X-rays  are 
given  off  by  the  glass  walls  as  well  as  by  the  other  metal  electrodes  of  the 
tube,  in  addition  to  the  bulk  of  the  X-rays  emanating  from  the  anti-cathode. 
Owing  to  the  presence  of  inverse  current  in  the  tube,  some  cathode  rays  are 
produced  from  the  anode,  and  others  also  start  from  the  edges  of  the  cathode, 
and  these  are  all  converted  into  secondary  X-rays. 

These  secondary  X-rays,  which  are  produced  in  much  larger  quantities 
in  hard  than  in  soft  tubes,  are  the  primary  cause  of  lack  of  definition,  detail, 
and  contrast ;  they  produce  general  fog  in  negatives,  and  so  lessen  the 
value  of  the  results  of  the  more  difficult  radiographs. 

The  compressor  apparatus  consists  of  a  lead-lined  metal  cylindrical  or 
rectangular  box,  with  an  opening  at 
the  upper  end  for  the  insertion  of 
diaphragms.  The  cylinder  effectu- 
ally absorbs  and  screens  off  all  stray 
secondary  rays,  allowing  only  those 
X-rays  emanating  from  the  anti- 
cathode  to  reach  the  photographic 
plate.     This  can  be  proved  at  any 

time     by     observing     a     fluorescent     f^g.  gg.-Extension  tube  of  a  Kidwig  compressor 
screen    placed    below    the    cylinder,        to  show  method  of  compression.      (Siemens. ) 

when  a  brightly  illuminated  centre 

only  will  be  seen  ;  a  wider  circle  of  fluorescence,  indicating  the  presence  of 

stray  secondary  rays,  is  only  observed  when  inefficient  diaphragms  are 

employed. 

By  the  time  the  X-rays  have  traversed  the  distance  between  the  tube 
and  the  fluorescent  screen  or  photographic  plate,  they  have  become  very 
much  diffused,  and  the  thicker  the  subject  the  greater  the  diflusion.  The 
primary  object,  therefore,  is  to  reduce  this  distance  in  order  to  obtain  quicker 
exposure  and  sharper  and  more  brilhant  radiographs,  and  for  this  purpose 
it  is'  necesary  to  combine  a  compressor  with  the  cylinder.  The  end  of  the 
cylinder  is  fitted  with  an  ebonite  rim,  and  the  whole  apparatus  is  raised 
and  lowered  by  a  lever. 

Some  parts  of  the  human  body  can  be  compressed  three  or  four  inches 
without  causing  any  discomfort  to  the  patient,  and  the  time  of  exposure  is 
thus  very  greatly  reduced.  The  compressor  is  also  of  great  use  in  reducing 
the  movement  due  to  respiration,  and  thereby  conduces  to  greater  sharpness 
and  definition  in  the  radiograph. 

There  are  modifications  of  this  type  of  compressor  which  are  preferred 
by  some  workers,  and  possess  advantages  over  the  Albers-Schonberg.  The 
compressor  introduced  by  Dr.  Gilbert  Scott  possesses  all  the  advantages 


70 


RADIOGRAPHY 


of   the  Schonberg  apparatus,  and  is  much  more  adaptable  and  easy  of 
manipulation. 

The  Upright  Screening"  Stand. — This  useful  piece  of  apparatus  may 
be  simple  or  very  complicated,  with  conveniences  for  stereoscopic  exposures. 
All  movements  must  be  easy.  Several  types  of  screening  stands  are 
illustrated.     The  most  useful  are  Levy-Dorn,  Wenckebach,  the  extremely 


Fig.  70. — Screening  stand  arranged  for  stereoscopic  work  in  the  ^ipright  position. 

(Butt.) 

The  apparatus  is  arranged  so  that  tube-  and  plate-holder  move  automatically  at  the 
right  moment.     The  whole  mechanism  is  controlled  from  the  switch  table. 


ingenious  but  complicated  one  designed  by  Schmidt  of  Berlin,  and  the 
apparatus  of  Butt  with  automatic  stereoscopic  movements.  Care  should 
be  taken  to  ensure  the  complete  protection  of  the  operator.  The  fluor- 
escent screen  should  have  protected  handles,  and  the  front  must  be  pro- 
tected by  thick  lead  glass.  This  should  be  tested  to  make  sure  that  it  is 
efficient. 

The  Levy  Dorn  Screening  Stand  is  constructed  in  such  a  manner  that  it 


SCREENING  STAND 


71 


can  be  used  for  other  purpo'ses  in  addition  to  screening,  and  so  it  forms 
a  very  complete  type  of  apparatus,  particularly  in  small  hospitals  where 
the  space  devoted  to  the  X-ray  department  is  very  limited.  The  ap- 
paratus consists  essentially  of  a  large,  totally  enclosed  protective  lined 
tube-box,  with  lead-glass  observation  window  fitted  with  sliding  shutter 
on  one  side  ;  at  the  back  is  a  door  and  on  the  front  is  fitted  the  dia- 
phragm, compressor  tube,  and  other  pieces  of  apparatus.  This  tube-box  is 
mounted  on  a  carrying  frame,  which  is  fitted  A\dth  slots,  so  that  it  can  be 
brought  nearer  or  taken  further  from  the  patient,  also  the  whole  box  can 
be  entirely  rotated.  The  frame  carrying  the  tube-box  is  attached  to  a  strong 
square  framework,  running  up  and  down   between  the  upright  sides   of 


Fig.  71. — Screening  stand  arranged  for  work 
beneath  the  table.     (Siemens. ) 


Tig.  72. — Screening  stand  arranged  for  examina- 
tions in  the  upright  position.     (Siemens.) 


the  stand.  This  frame  is  fitted  with  counterweights,  so  as  to  move  freely 
up  and  down,  and  on  the  front  of  it  are  two  rods  projecting  forward,  and 
sliding  on  these  rods  is  a  metal  carrier  and  carriage  for  holding  the  fluorescent 
screen  or  plate-holder,  which  can  be  angled  to  follow  the  contour  of  any  part 
it  is  desired  to  examine  or  radiograph.  The  whole  of  the  control  of  this  ap- 
paratus can  be  manipulated  from  the  front,  so  that  it  is  entirely  unnecessary 
for  the  operator  to  put  his  hands  near  the  tube-box.  As  will  be  seen, 
the  fluorescent  screen  can  be  moved  freely  across  the  patient  by  means  of 
its  own  protective  handles  ;  the  aperture  of  the  diaphragm  is  controlled  by 
means  of  the  two  flexible  cables  and  handles  seen  on  the  right  in  Fig.  71  ; 
the  handle  on  the  left-hand  side  causes  the  tube-box  to  travel  from  side  to 
side  at  the  back,  and  the  large  wheel  seen  on  the  right  is  for  raising  and  lower- 
ing the  whole  of  the  frame  carrying  the  tube-box  and  screen-carrier.     Now, 


72 


KADIOGKAPHY 


Fig,  73. — Screening  stand  arranged  to  work  as  a 
compressor.     (Siemens. ) 


as  to  its  other  purposes,  the  tube-box  can  be  lowered  to  the  ground  and 
rotated,  a  quarter-revolution  bringing  the  opening  of  the  tube-box  towards 

„,  the  ceiling  of  the  room.  A  couch  or 
table  can  be  moved  over  the  box  in 
this  position,  and  examinations  and 
radiographs  made  with  the  tube 
below.  Or,  on  the  other  hand,  the 
tube-box  can  be  rotated  from  its 
screening  position  a  quarter-turn  in 
the  other  direction,  so  that  the  aper- 
ture is  towards  the  floor.  The  frame 
carrying  the  tube-box  can  be  now 
raised  upwards,  a  compressor  tube 
affixed,  and  the  front  of  the  box 
and  a  couch  or  table  passed  under 
or  through  the  stand.  The  tube- 
box  can  now  be  lowered,  and 
compression  work  undertaken  as 
with  an  Albers  -  Schonberg  com- 
pressor. If  the  tube-box  be  rotated 
a  half-revolution,  then  the  patient 
can  be  brought  close  up  to  the 
diaphragm,  and  on  the  other  hand 
tele-radiographs  can  be  accurately  made  with  the  aid  of  a  simple  centering 
arrangement  provided  with  the  apparatus. 

The  Wenckebach  Screening  Stand  is  somewhat  different,  and  is  con- 
structed for  screen  examinations  and  exposures  from  the  screening  position 
only.  It  is,  however,  an  excellent  stand  for  those  specialising  in  screen 
examinations.  It  is  constructed  in  two  units.  One  unit  might  be  called  the 
screen  unit  and  the  other  the  tube-box  unit.  The  former  consists  of  a  frame 
carrying  the  fluorescent  screen  and  plate-holder,  which  fits  into  a  parchment 
frame  marked  with  divisions,  so  that  a  note  can  be  made  of  the  exact  position, 
and  an  examination  repeated.  This  frame  and  screen  is  counterbalanced, 
and  can  be  easily  raised  or  lowered  in  a  large  upright  framework.  On  the 
back  of  this  framework  are  fitted  at  convenient  intervals  bands  for  passing 
round  the  patient  to  keep  him  in  a  fixed  position.  There  is  also  a  lamp 
which  throws  a  light  on  the  scales  of  the  second  part  of  the  apparatus.  The 
latter  or  second  part  consists  of  a  large  protective-lined  tube-box,  mounted 
on  a  frame  which  is  carried  on  a  second  upright  framework,  and  from  this 
project  forward,  one  on  either  side,  two  long  arms  with  convenient  wheel 
handles,  one  on  the  left-hand  side  for  raising  and  lowering  the  tube-box, 
and  one  on  the  right  for  moving  it  across  from  side  to  side  ;  also  close  beside 
the  latter  are  the  two  flexible  cables  and  handles  for  controlling  the  aperture 
of  the  diaphragm.  This  second  part  is  mounted  on  rails  laid  in  the  floor,  and 
the  object  of  the  long  arms  is  that  the  operator,  while  maldng  his  screen 
examination,  can  push  the  tube  further  away,  or  draw  it  nearer  the  patient 


UNIVERSAL  PROTECTIVE  STAND 


73 


with  the  utmost  comfort  and  ease.     A  stool  can  also  be  provided  to  support 
the  patient  if  necessary. 


Fig.  74, — Wenckebach  .screening  stand. 
(Siemens.) 


Fig.  75. — Wenckebach  screening 
(Siemens. ) 


Universal  Safety  and  Protective  Tube-stand. — The  demand  for 
a  universal  apparatus  is  increasing  as  the  real  importance  of  the  Rontgen 
examination  of  the  internal  organs  is  recognised.  There  are,  of  course, 
various  devices  for  radiographing  the  patient  in  a  standing  or  sitting  position, 
but  a  simple  and  handy  universal  apparatus  for  both  fluoroscopy  and  radio- 
graphy is  much  to  be  desired.  The  desiderata  of  such  an  apparatus  are 
many.  The  most  important  of  .these  are  the  fixation  of  the  body,  the 
straightness  of  the  trunk,  and  the  accurate  adjustment  of  the  normal  ray 
to  any  desired  point  on  the  surface.  In  addition,  any  such  apparatus,  if 
it  is  to  be  universal,  must  be  equally  efl&cient  when  the  patient  is  reclining, 
sitting,  or  standing,  and  should  be  easily  adjustable  for  tele-radiography  up 
to  a  distance  of  2  metres  or  more.  Finally,  it  should  be  capable  of  being 
easily  and  quickly  handled,  and  it  should  not  be  too  expensive. 

First,  as  to  the  straightness  of  the  trunk.  It  is  absolutely  essential  that 
this  should  be  as  accurate  as  possible  for  exact  radiography,  and  for  locaUsa- 
tion  and  measurement  of  the  internal  organs.  Straightening  by  the  eye  is 
quite  inadequate.  The  difficulty  may  be  overcome  satisfactorily  by  a 
mechanical  device  which  carries  out  this  straightening  automatically.  The 
trunk  is  often  moved  during  the  exposure,  even  by  intelligent  patients,  and 
the  picture  thereby  spoilt.  This  difficulty  is  partially  overcome  by  in- 
stantaneous exposures  of  one-hundredth  of  a  second  or  less  ;  but,  never- 
theless, an  efficient  means  of  holding  the  patient  is  absolutely  necessary 
since  no  movement  should  take  place  between  the  completion  of  the  adjust- 


74 


KADIOGEAPHY 


ment  of  the  part  to  be  radiographed  and  the  exposure  of  the  negative. 
Moreover,  it  is  of  importance  to  minimise  to  a  certain  extent  the  costal  and 
abdominal  respiratory  movements,  especially  in  the  radiography  of  the 
kidneys. 

The  apparatus  shown  in  Fig.  76  is  constructed  from  this  point  of  view. 
It  consists  of  a  heavy  base  and  framework,  with  a  well-protected  tube-box, 
which  can  be  moved  in  all  directions,  the  fluorescent  screen  being  suspended 
by  cords  and  counterpoises.  There  is  in  addition  a  special  tube  adjustment, 
and  a  set  of  rails  and  a  small  table  for  distance  radiography. 

The  fixation  board,  which  will  take  a  plate-holder  of  any  size,  is  furnished 
mth  three  pairs  of  padded  clamps,  each  pair  being  moved  by  the  simple  turn- 
ing of  a  single  handle,  so  that  they 
are  always  at  the  same  distance 
from  the  middle  line  of  the  board. 
The  upper  pair  are  made  in  the 
form  of  well -padded  shoulder- 
caps,  inclined  in  such  a  manner 
that,  when  brought  together,  they 
hold  the  patient's  shoulders 
firmly,  and  at  the  same  time 
press  them  against  the  plate- 
holder.  To  the  top  edge  of  the 
board  is  attached  an  adjustable 
support  for  the  chin.  Between 
the  two  lower  pairs  of  clamps  is  a 
broad  compression  band,  which 
can  be  readily  tightened  up  by 
turning  a  handle.  Another 
handle  can  raise  or  depress  the 
plate-holder,  so  that  even  after 
the  fixation  of  the  trunk  the 
plate  may  be  brought  to  any  re- 
quired height,  or  depressed  as 
much  as  20  centimetres  below 
the  board,  for  radiography  of  the  pelvic  organs. 

In  the  centre  of  the  supporting  board  is  a  large  opening  for  the  diaphragm 
tube,  for  use  in  radioscopy.  There  is  also  a  receptacle  for  small  cross-shaped 
lead  labels,  backed  with  plaster,  which  can  easily  be  attached  to  any  portion 
of  the  skin. 

For  radiography  in  a  reclining  position  the  fixation  board  may  be 
detached  from  the  framework.  As  it  weighs  only  40  pounds,  it  can  easily 
be  carried  by  one  person,  and  placed  on  the  X-ray  table  or  ambulance. 

The  framework  is  6  feet  high,  and  is  mounted  on  castors.  It  is  provided 
with  a  small  wooden  frame  with  counterpoises,  which  is  easily  adjustable  by 
means  of  a  hand-wheel  at  the  back.  This  carries  the  fixation  board  and 
clamps,  and  the  guide  rails  for  the  tube-box  and  fluorescent  screen. 


Fig 


itaud. 


7tj. — Auseful  forui  of  universal  exauiiuin 
(Siemens. ) 

This  combines  nearly  all  the  movements  that  are 
necessary  for  a  complete  examination,  and  is  efficiently 
protected. 


USES  OF  THE  UNIVEKSAL  STAND  75 

For  radiography  of  the  stomach,  the  fixation  board  may  be  brought 
forward  in  an  inclined  position  by  means  of  two  hinged  wooden  flaps. 

The  tube-box  travels  along  the  guide  rails  by  means  of  an  endless  screw, 
and  can  be  moved  vertically  as  well  as  horizontally.  The  trolley  which 
carries  the  spindle  is  locked  in  the  central  position  by  a  spring,  thus  giving 
at  once  the  position  in  which  the  focus  of  the  tube  and  the  normal  ray  are  in 
line  with  the  centre  line  of  the  fixation  board,  and  therefore  with  the  axis 
of  the  patient's  body.  The  guide  rails  are  graduated  so  as  to  give  the  exact 
distance  of  the  focus  from  the  plate.  The  tube  is  centred  once  for  all  by 
means  of  an  adjustment  tube  attached  to  the  diaphragm.  It  is  supported 
in  its  wooden  box  by  a  wooden  screw  and  three  pads  covered  with  felt. 

The  focus-tube  adjuster  is  a  tube  at  right  angles  to  the  plate  and  the 
body  of  the  patient.  This  is  moved  about  by  a  special  sHde  till  its  aperture 
coincides  with  a  point  on  the  surface  of  the  body  which  has  previously  been 
marked  by  a  lead  label.  In  order  to  focus  the  central  normal  ray,  this 
tube  is  adjusted  till  the  lead  label  coincides  with  the  crossed  threads  in  the 
tube,  reflected  by  a  small  mirror,  and  viewed  through  a  lateral  eyepiece. 
The  tube-adjuster  is  thus  in  every  position  perpendicular  to  the  plane  of  the 
photographic  plate,  and  its  extremity  is  always  exactly  50  centimetres  from 
the  plate.  At  the  side  of  the  tube-box  is  a  spring  tape-measure,  by  means  of 
which  the  exact  focus  distance,  up  to  2  metres  or  more,  may  be  determined. 

The  fluorescent  screen  is  suspended  by  cords  and  counterpoises,  and 
moves  up  and  down  in  exact  correspondence  with  the  tube-box.  Its  move- 
ment is  effected  by  means  of  a  hand-wheel  at  the  back  of  the  apparatus. 

For  distant  radiography  the  rails  are  attached  to  the  foot-board,  and  a 
small  table  on  three  wheels  placed  on  the  rails.  The  tube-box  is  unscrewed 
from  the  spindle,  and  fixed  in  a  slot  in  the  far  side  of  this  table. 

The  principal  uses  of  the  apparatus  are  : 

1.  Radioscopy  of  the  internal  organs,  under  absolutely  constant  con- 
ditions, 

2.  Distant  exposures  (2  metres)  with  the  patient  vertical  or  horizontal. 

3.  Radiographic  exposures  of  all  kinds  (universal  tube-stand). 

The  examination  of  the  internal  organs  may  be  made  in  the  rechning, 
standing,  or  sitting  positions.  In  order  to  straighten  and  fix  the  trunk, 
it  is  advisable,  first,  to  bring  the  shoulder-caps  in  light  contact  with  the 
shoulders,  and  then  to  lower  the  whole  fixation  board,  with  the  attached 
overhead  rails,  firmly  on  to  the  shoulders,  so  that  they  are  exactly  at 
the  same  height.  The  handle  is  then  turned  until  the  shoulders  are  firmly 
pressed  back  against  the  plate-holder.  When  placed  against  the  pads,  the 
patient  will  naturally  assist  the  adjustment  by  moving  towards  one  side  or 
the  other,  until  the  pressure  of  both  sides  is  sensibly  equal.  The  trunk 
itself  is  pressed  against  the  plate,  by  tightening  up  the  compressor  band 
by  means  of  the  fourth  handle. 

After  the  patient  has  been  fixed,  the  plate  may  be  brought  into  the  best 
position  by  turning  the  handle.  The  next  thing  is  to  mark  with  a  lead 
cross  the  point  on  the  surface  of  the  body  which  has  to  be  f ocussed,  and  the 


76  RADIOGKAPHY 

centering  tube  is  brought  into  immediate  contact  with  this  cross.  Since  this 
little  focussing-tube  is  exactly  in  the  centre  line  of  the  apparatus  when  held 
by  the  spring  catch  on  the  transverse  rail,  the  centre  line  of  the  body — for 
instance,  one  of  the  spinous  processes — must  be  brought  into  line  with  the 
tube  by  slightly  turning  the  trunk.  The  tube  may  now  be  run  back  to  the 
required  distance  as  measured  on  the  guide  rails,  and  the  normal  ray  remains 
accurately  adjusted  with  regard  to  the  specified  point  on  the  surface  of  the 
body  ;  it  may  easily  be  readjusted  at  any  time  if  required.  For  long 
exposures  the  tube-box  can  be  kept  more  steady  by  supporting  it  also  on 
the  small  table.  With  a  little  practice  the  whole  process  of  straightening  the 
trunk  and  fixing  it,  together  with  focussing  and  bringing  the  ray  vertically 
on  to  the  plate  and  determining  the  distance  of  the  tube,  can  be  performed 
in  under  one  minute. 

For  a  "  standard  exposure,"  the  question  of  the  distance  of  the  focus- 
tube  from  the  plate  is  of  the  greatest  importance.  This  "  focus  distance  " 
should  be  constant.  It  is  a  matter  of  some  difiiculty  to  determine 
whether  to  make  the  "  standard  exposure  "  a  short  one,  getting  a  sharp 
picture,  but  with  considerable  distortion ;  or  whether  to  make  it  a 
distance  exposure,  say  at  2  metres,  with  Httle  distortion,  but  faint  and 
often  with  hardly  satisfactory  definition.  Apparently,  there  is  only  one 
solution  of  the  problem  at  the  present  time — namely,  to  have  two  "  standard 
focus  distances  "  :  70  centimetres  for  near  exposure,  and  2  metres  for 
distance  exposures. 

The  advantage  of  telerontgenography  as  avoiding  distortion  admits  of 
little  doubt,  but  this  is  of  slight  service  at  present,  when  such  exposures 
are  very  seldom  successful.  The  principle  of  the  "  standard  exposure  " 
necessitates  conditions  which  are  easily  reahsable  by  any  one,  viz.  a  near 
exposure  of  70  centimetres.  Such  an  exposure  may  now  be  made  satis- 
factorily in  a  very  short  time.  The  focussing  for  a  "  standard  exposure  " 
can  be  carried  out  suitably  once  for  all  on  the  axis  of  the  body,  in  which 
case  the  distortion  of  any  internal  organ,  such  as  the  heart,  in  the  region  of 
the  centre  line,  is  extremely  shght.  There  remains  a  distortion  of  the  con- 
tours towards  the  periphery.  Alban  Kohler  and  others  have  shown  that 
the  displacement  of  the  image  of  the  left  edge  of  the  heart  is  greater  by 
1  centimetre  with  a  focus  distance  of  70  centimetres  than  with  a  focus 
distance  of  2  metres.  This  error  of  1  centimetre  need  not  cause  any  per- 
plexity so  long  as  it  is  constant,  and  in  proportion  to  the  whole  thorax  picture 
and  to  the  surface  landmarks.  If,  for  example,  we  have  projected  on  the 
plate  the  mammillary  line,  a  radiogram  taken  under  similar  conditions  will 
always  show  the  outer  edge  of  the  heart  in  a  definite  relation  to  this  line 
and  to  the  outer  boundary  of  the  thorax.  The  same  holds  good  for  disten- 
sion of  the  aorta  and  for  other  departures  from  the  normal.  One  can  there- 
fore make  a  diagnosis  from  the  plate  alone,  on  the  assumption  that  the 
exposure  is  a  "  standard  "  one.  The  distance  of  70  centimetres  is  recom- 
mended because  it  strikes  the  mean  between  distortion  and  good  definition 
in  the  negative.     The  tube-director  of  the  apparatus  is  adjusted  for  this 


"  STAND AED"   EXPOSURES  77 

focus  distance  of  70  centimetres,  so  that  no  measurement  whatever  is  neces- 
sary. Moreover,  a  locking  device  is  attached  to  the  guide  rails  at  70  centi- 
metres, so  that  the  standard  distance  is  oVjtained  automatically. 

Finally,  in  order  to  give  an  indication  on  each  plate  that  the  "  standard 
exposure  "  has  been  given,  the  position  of  the  normal  ray  is  indicated  on  each 
plate  by  the  projection  of  the  lead  label  on  the  specific  "  landmark."  This 
is  a  check  on  the  whole  adjustment,  and  at  the  same  time  a  characteristic 
sign  of  the  particular  normal  exposure  in  question.  As  these  anatomical 
points  are  constant  for  each  region,  they  serve  the  purpose  much  better  than 
the  umbilicus  usually  employed,  which  is  seldom  selected  as  the  focussing- 
point,  and  consequently  varies  in  the  position  of  its  projection. 

The  following  are  the  specific  normal  points,  or  Rontgen  landmarks, 
for  the  examination  of  the  internal  organs.  They  are  all  on  the  median  line 
of  the  body. 

Standard  Points  on  the  Median  Lines  at  Various  Levels. 

Chest:   1.  The  xyphoid  process  (anterior  position). 

2.  The   line   between  the  angles  of   the   scapulae   (posterior 
position). 

Abdomen  :   3.  Line  between  the  spines  of  the  ilia  (anterior  position). 

4.  Line  of  the  iliac  crests  (posterior  position). 

Pelvis  :   5.  The  lower  edge  of  the  symphysis  pubis. 

6.  The  tip  of  the  coccyx. 

The  landmark  for  the  "  standard  exposure  "  of  the  hip- joint  is  the  centre 
of  Poupart's  hgament.     This  is  the  only  landmark  which  is  not  median. 

A  flexible  ruler  is  supplied  with  the  apparatus,  which  renders  it  easy  to 
obtain  the  exact  position  of  the  adherent  lead  disc,  by  marking  on  the  skin 
the  intersection  of  the  median  line  with  the  transverse  line. 

Such  anatomical  points  or  landmarks  have,  however,  the  disadvantage 
that  they  cannot  in  every  case  be  accurately  determined,  and  are  not  always 
quite  constant.  With  the  Universal  Apparatus,  therefore,  a  set-square  is 
supplied,  which  gives  the  Rontgen  landmarks  without  further  measurement. 
By  a  very  simple  device  the  distance  from  the  shoulder  to  the  crest  of  the 
ilium  is  measured,  and  divided  into  three  equal  sections.  The  upper  division 
gives  the  level  of  the  Rontgen  point  for  chest  exposures,  and  the  lower 
division  for  stomach  exposures,  whether  dorso-ventral  or  ventro-dorsal. 
These  points  are  absolutely  constant  and  easy  to  determine. 

When  reference  is  made  to  a  "  standard  radiogram  "  of  an  internal 
organ,  the  first  thought  is  of  the  heart,  as  the  great  aim  of  X-ray  technique 
has  always  been  to  provide  an  accurate  and  useful  picture  of  this  vital  organ. 
When  it  was  impossible  to  reproduce  the  actual  size  of  the  heart,  and  even 
pictures  with  a  similar  amount  of  distortion  could  not  be  obtained,  the 
orthodiagraph  was  devised  to  provide  a  tracing  of  the  organ  from  a 
number  of  isolated  points.  At  that  time  exposures  of  the  internal 
organs   were   considerably  below  the   present  standard.     By  making  an 


78  RADIOGEAPHY 

orthodiagram  one  obtained,  at  any  rate,  a  dotted  normal  projection 
of  this  organ,  even  although  it  was  influenced  somewhat  by  the  personal 
factor  of  the  operator.  There  were  in  addition  several  sources  of  error 
due  to  the  process  and  to  movements  of  the  patient.  All  these  dis- 
.advantages  are  avoided  by  the  use  of  the  modern  rapid  exposure  with 
reinforcing  screen.  Moreover,  it  is  difficult  to  take  an  entire  orthodiagram 
during  the  same  phase  of  diastole,  and  the  drawing,  which  requires  some 
time  to  make,  often  shows  one  part  in  diastole,  another  in  systole.  The 
tracing,  therefore,  often  affords  a  much  less  accurate  diagnosis  than  the 
photograph  in  which  we  have  the  united  product  of  diastole  and  systole,  and 
the  contours  are  constant,  and  in  their  true  relation  to  the  margin  of  the 
thorax  and  other  landmarks.  By  means  of  the  small  adjustable  sector, 
it  is  easy  to  determine  on  the  plate  the  constant  line  midway  between  the 
axis  of  the  body  and  the  outer  edge  of  the  ribs  at  the  level  of  the  diaphragm. 
The  normal  heart  does  not  project  beyond  this  hne,  and  its  margin  forms 
n  definite  angle  with  the  axis,  which  may  be  measured  by  the  diagonal  of 
the  instrument.  If  now  the  sector  be  laid  on  the  patient's  chest,  and  the 
constant  middle  line  is  displaced  1  centimetre  inwards,  so  as  to  correct  for 
distortion  of  the  shadow,  we  may  draw  the  actual  size  of  the  heart  on  the 
skin,  and  check  it  by  the  image  on  the  plate.  In  any  case,  this  so-called 
"  constant  middle  fine  "  provides  a  landmark  which  is  much  more  trustworthy 
than  the  extremely  variable  mammillary  line.  This  constant  line  may  be 
easily  determined  by  using  the  sector. 

In  conclusion,  we  would  draw  attention  to  the  importance  of  the  "  stand- 
ard exposure  "  for  examinations  of  the  intestinal  tract,  where  we  have  often 
to  make  a  series  of  successive  exposures  of  the  same  patient.  An  accurate 
comparison  is  impossible,  except  when  the  pictures  have  been  made  under 
exactly  similar  conditions.  Further,  it  is  of  the  greatest  importance  to  know 
precisely  the  position  of  the  pylorus,  the  fundus  ventriculi,  and  the  transverse 
colon.  The  possibility  of  incorrect  diagnosis  in  consequence  of  variable 
•adjustments  should  be  altogether  excluded. 

Universal  Examining"  Chair. — This  chair  is  used  chiefly  for  screen 
work  and  for  superficial  radiographs.  The  chief  object  in  view  in  the  design 
rof  the  chair  is  to  obtain  as  exact  and  as  reliable  a  fixed  position  for  the 
patient  as  possible.  This  is  obtained  by  two  wide  straps  fixed  to  the  sail- 
cloth back  of  the  chair,  which  hold  the  patient  in  an  upright  position,  and  by 
two  easily  adjustable  axle  supports,  which  prevent  any  movement  sideways. 
'The  feet  are  well  supported  by  a  footstool,  which  may  be  adjusted  to  any 
ieight.  When  taking  screen  observations  of  the  stomach,  the  seat  can  be 
leplaced  by  a  bicycle  saddle,  which  is  better  suited  for  this  work. 

In  order  that  the  observer  can  undertake  the  examination  of  these  parts 
in  the  most  comfortable  position,  and  without  bending,  it  is  necessary, 
-after  fixing  the  patient,  to  bring  him  to  the  height  desired  by  the  observer. 
This  is  attained  by  an  oil  pump  which  is  built  into  the  very  massive  base  of 
the  chair,  and  which  is  operated  by  pressure  of  the  foot  on  a  pedal.  The 
locking  of  the  chair  takes  place  automatically  after  the  foot  is  removed. 


EXAMINING  CHAIR 


79 


The  fluorescent  screen  necessary  for  observation  is  secured  by  a  holder 
fixed  to  the  arms  of  the  chair,  and  may  be  adjusted  in  all  directions.  In 
addition,  the  screen  can  be  removed  very  easily,  so  that  it  may  be  replaced 
quickly  by  a  dark  slide  contain- 
ing the  photographic  plate. 

Should  it  be  desired,  after  the 
examination  has  been  completed, 
to  bring  the  patient  back  into  the 
original  position,  it  is  only  neces- 
sary to  depress  the  second  small 
pedal  in  order  to  release  the 
locking  device.  Thereupon,  the 
chair  sinks  slowly  into  the  original 
position,  owing  to  the  excellent 
braking  power  of  the  pump. 

The  chair  can  be  moved 
about  easily,  and  may  also  be 
turned  round  its  vertical  axis  with 
the  foot,  so  that  the  hands  of  the 
radiographer  need  never  come  in 
the  path  of  the  rays. 

Rieder's  Exposure  Stand. 
— Another  very  useful  piece  of 
apparatus  is  an  exposure  stand, 
originally  used  by  Dr.  Rieder  for 
taking  radiographs,  with  the 
patient  either  sitting  or  standing. 
It  is  specially  suitable  for  thorax, 
stomach,  and  abdomen  exposures. 

Another  valuable  addition  is 

a      little      protective      lead-lined  Fig.    77.— Examining  chair    fitted   with    mechanical 
screen,   with   an  adjustable  lead-       .r^^'^^^'^ts  to  facilitate  the  rapid  manipulation  of 
'    _  J  _  the  patient.      (Siemens. ) 

lined  sliding  leaf,  arranged  with  a 

clamp  for  fluorescent  screen  and  plate-holder.  This  little  apparatus  should 
be  mounted  on  good  castors  so  as  to  move  freely,  and  it  can  be  used  for 
many  purposes.  It  is  constructed  primarily  for  the  protection  of  the  operator 
when  screening,  but  it  can  also  be  used  for  the  patient  to  stand  against,  and 
to  support  himself  whilst  being  radiographed.  It  can  be  used  in  conjunc- 
tion with  any  X-ray  couch,  screening-stand,  or  tube-stand,  and  also  if  a 
long  therapeutic  appHcation  has  to  be  made  this  screen  can  be  placed 
between  the  operator  and  the  tube,  so  that  no  radiation  from  the  latter 
falls  on  the  operator. 


THE  ARRANGEMENT  OF  APPARATUS 

In  a  work  of  this  size  it  is  difficult  to  deal  adequately  with  so  wide  a 
subject,  but  for  practical  purposes  it  will  be  sufficient  to  describe  : 

(1)  A  small  installation. 

(2)  An  installation  for  a  general  hospital  or  consulting  radiologist. 

(3)  An  installation  for  a  special  hospital. 

(4)  An  installation  (a)  for  a  hospital  for  military  service,  (6)  for  field 
service. 

Each  scheme  will  be  capable  of  modifications  according  to  local  demands, 
but  the  basis  of  each  should  form  a  working  nucleus  upon  which  the  individual 
operator  may  build  a  complete  scheme.  A  scheme  for  the  arrangement  of 
apparatus  and  a  system  of  dealing  mth  photographic  details  will  also  be 
included.  A  system  of  filing  negatives  and  reports  should  be  adopted  in 
every  department. 

1.  A  Small  Installation 

There  is  a  demand  for  small  installations  to  meet  the  needs  of  practi- 
tioners desirous  of  examining  their  cases  in  the  course  of  ordinary  consulta- 
tion, of  school  clinics,  especially  those  where  treatment  is  carried  out,  and 
where  occasional  radioscopic  examination  is  required,  and  finally  of  small 
hospitals,  where  for  various  reasons  an  elaborate  installation  is  not  possible. 

A  comparatively  large  coil  (say  15-inch  spark-gap)  is  desirable.  Further, 
a  simple  control  apparatus  is  required,  either  mounted  on  the  wall  or  pre- 
ferably on  a  wheeled  trolley  ;  and  a  mercury  interrupter,  with  dielectric  of 
paraffin  or  preferably  of  gas  ;  when  rapid  exposures  are  desired,  an  electro- 
lytic interrupter  should  be  added,  and  this  necessitates  a  change-over  switch 
in  the  control  apparatus.  In  order  to  suppress  reverse  current,  an  adjustable 
spark-gap,  introduced  in  the  secondary  circuit,  is  sufficient  where  small 
currents  are  used  ;  while  for  heavier  discharges,  obtained  by  using  the 
electrolytic  interrupter,  valve  tubes  are  necessary.  A  suitable  tube-holder, 
with  efficient  protection  and  with  the  necessary  fittings  for  therapeutic  work 
is  required,  viz.  tripod  for  treatment  of  ringworm,  pastille  holder,  filters, 
etc.  A  simple  examination-table  with  three-ply  wood  or  canvas  top,  and  a 
simple  screening-stand  are  requisite.  A  vellum  window  may  be  fitted  into 
a  wooden  frame  which  can  be  moved  to  any  portion  of  the  couch.  This 
allows  practically  all  the  rays  to  pass  through  to  the  fluorescent  screen, 
and  gives  the  maximum  value  in  screening.  These  may  be  combined  in 
an  apparatus  which  may  be  used  for  either  purpose.     A  fluorescent  screen, 

80 


ARRANGEMENT   OF  APPARATUS 


81 


protected  with  lead  glass  and  provided  with  hand-guards,  a  supply  of 
X-ray  tubes,  X-ray  proof  gloves,  Benoist  radiometer,  oscilloscope  tube, 
milliamperemeter,  and  photographic  plates  are  also  necessary.  When 
instantaneous  exposures  are  to  be  carried  out,  a  casette  for  plates  with  an 
intensifying  screen  must  be  added. 


SijiniermeteT 


Fig.   78. —  Aconveuient  form  of  apparatus  arranged 
on  an  upright  cabinet.      (Watson.) 


Fig.  79.— To  illustrate  the  parts  as 
arranged  in  Fig.  78. 


Portable  Apparatus.— This  may  take  the  form  of  a  trolley  outfit 
in  a  compact  cabinet,  capable  of  being  wheeled  from  ward  to  ward,  and 
obtaining  its  current  supply  from  the  electric  mains.  For  work  in  private 
houses  or  institutions  unprovided  with  electrical  installation,  it  is  necessary 
to  have  an  outfit  which  derives  its  current  supply  from  accumulators. 
Essentially  it  is  the  same  as  the  small  installation  described  above,  but  a 
12-inch  coil  is  for  various  reasons  more  convenient.  A  mercury-interrupter 
of  the  "  Sanax  "  type  is  convenient ;  a  tube-stand  of  lighter  construction 
and  a  portable  examination  table  may  be  added.     The  connections  of  the 


82  RADIOGEAPHY 

accumulators  are  illustrated  in  the  accompanying  diagram.  When  exposing 
plates  with  a  portable  apparatus,  a  casette  and  intensifying  screen  should  be 
used,  as  these  greatly  shorten  the  length  of  exposure. 


2.  Installation  for  a  General  Hospital  or  Consulting 

Radiologist 

The  essential  features  of  a  somewhat  more  complex  installation  may  be 
briej&y  enumerated. 

(a)  One  or  more  coil  outfits,  with,  where  possible,  a  powerful  instrument, 
such  as  a  high-tension  rectifier,  a  Snook  machine,  or  a  powerful  coil  outfit 
fitted  with  three  breaks  (mercury  with  gas  dielectric,  triple  Wehnelt,  and,  if 
possible,  a  single-impulse  switch).  With  a  high-tension  rectifier  apparatus 
one  can  add  a  single-impulse  switch. 

(6)  A  second  outfit  of  less  capacity  is  useful  as  a  stand-by  in  case  of  a 
break-down.  This  is  an  important  point,  because  in  a  large  institution 
work  must  go  on  constantly. 

(c)  Overhead  high-tension  cables,  properly  insulated,  should  be  stretched 
from  one  end  of  the  room  to  the  other. 

{d)  A  change-over  switch  is  useful  when  two  installations  are  used, 
and  another  switch  for  quickly  connecting  to  various  pieces  of  apparatus. 
This  may  also  be  accompanied  by  adjustable  tube  leads,  running  on  wheels 
along  the  high-tension  cables.  The  plan  shown  on  p.  83  illustrates  the  best 
arrangement  of  apparatus  when  one  room  only  is  available.  The  various 
pieces  of  apparatus  are  marked  on  the  plan. 

The  dark  room  should  be  in  close  proximity  to  the  X-ray  room,  but 
care  should  be  taken  to  ensure  thorough  protection  of  the  unexposed  plates 
and  papers. 

For  large  institutions  a  suite  of  rooms  is  necessary.  The  plan  on  page 
84  shows  the  arrangement  of  rooms  at  King's  College  Hospital.  The 
rooms  are  marked  according  to  the  use  they  are  put  to.  When  a  separate 
building  is  available,  it  can  be  specially  planned  to  meet  the  requirements  of 
the  institution. 

Should  it  be  necessary  to  plan  an  X-ray  department,  great  care  should 
be  paid  to  the  arrangements  of  the  radiographic  room.  The  fighting  of  this 
room  should  be  carefully  planned.  A  large  window  means  that  trouble  will 
arise  when  it  is  necessary  to  darken  the  room,  consequently  the  smallest 
possible  window  space  must  be  allowed.  The  radiographic  room  must  be 
large.  It  should  have  in  close  proximity  to  it  a  waiting-room,  one  or  more 
dressing-rooms,  and  a  preparation-room  where  patients  may  be  anaesthetised 
or  an  opaque  enema  administered  prior  to  taking  the  patient  to  the  radio- 
graphic room.  This  room  should  have  an  adequate  supply  of  hot  and  cold 
water  and  other  conveniences.  These  additional  rooms  should  open  into 
the  radiographic  room.  Doorways  should  be  wide  enough  to  allow  of  the 
passage  of  a  large  trolley. 


83 


84 


EADIOGRAPHY 


Fig.  81. — Plan  of  the  X-ray  and  electrical  departments  at  King's  College  Hospital.     (By  kind 
permission  of  W.  A.  Pike,  Esq.,  F.R.I.B.A.) 
The   cubicles  marked  "electrical  treatment"  are  fitted  with  X-ray  installations.      The  room 
marked  "  dressings  "  has  since  been  fitted  up  as  an  operating-theatre  for  electro-coagulation  and 
for  operations  for  removal  of  foreign  bodies  under  X-rays. 


INSTALLATION  FOR  A  SPECIAL  HOSPITAL  85 


3.  Installation  for  a  Special  Hospital 

The  plan  of  an  Electrical  Institution  is  shown  on  page  86  ;  this  building 
was  specially  planned  for  the  purpose,  and  is  quite  complete  in  details. 
The  ground  floor  contains  a  waiting-hall  with  lavatory  accommodation, 
a  small  consulting- room  with  dressing-rooms, — the  former  fitted  \nth.  a 
desk,  filing  cabinet,  and  examination  lamps,  etc. 

The  Radiographic  Room. — This  contains  the  large  single-impulse 
apparatus,  with  the  regulating  apparatus  in  a  lead-lined  protection  cabinet. 
A  couch  and  screening-stand  form  the  chief  accessory  apparatus.  Cupboards 
for  tubes,  etc.,  form  part  of  the  furniture  of  the  room.  There  is  a  viewing- 
box,  to  take  two  15  by  12  negatives,  a  stereoscope,  and  a  large  viewing-box, 
to  take  six  15  by  12  plates,  each  with  removable  fronts,  adapted  to  hold 
smaller  plates.  Two  dark  rooms  adjoin  the  radiographic  room.  The  inner 
dark  room  is  fitted  with  the  viewing  apparatus,  which  will  be  described  in 
detail  later. 

The  First  Floor. — This  is  devoted  to  radio-  and  electro-therapy,  and 
has,  in  addition  to  the  special  X-ray  treatment  cubicles,  cubicles  for 
carbon- dioxide  snow  work,  radium  treatment,  diathermy,  the  mercury 
vapour  lamp,  Schnee  four-celled  bath,  and  galvanism  and  faradism. 

A  feature  of  this  room,  and  also  of  one  at  a  general  hospital,  is  a  small 
room  fitted  as  an  operating-room  for  diathermy,  electro-coagulation,  and 
operations  for  the  removal  of  foreign  bodies  under  X-rays.  A  photograph 
of  one  of  these  rooms  is  shown  on  page  266  to  give  some  idea  of  the 
arrangement  of  apparatus. 

The  Dark  Room. — When  a  large  amount  of  work  has  to  be  got  through 
it  is  necessary  to  have  a  large  and  well-equipped  dark  room,  with  possibly 
an  outer  dark  room.  This  should  contain  cupboards  for  plates,  papers,  etc. 
A  reducing  lantern  is  useful  for  the  supply  of  reduced  prints,  lantern  sHdes, 
etc.  The  dark  room  should  be  carefully  planned  to  facilitate  speedy  work- 
ing. The  entrance  should  be  carefully  guarded  by  two  doors  with  an  interval 
between.  It  is  an  advantage  to  have  them  so  arranged  that  the  two  cannot 
be  open  at  the  same  time.  Shelving  and  cupboard  accommodation  should 
be  provided.  The  ventilation  should  be  good,  and  the  heating  of  the  room 
should  be  carefully  attended  to.  Several  fights  are  required  :  (a)  Two  or 
more  ruby  lights ;  (6)  a  yellow  fight  for  printing,  etc.  The  development 
should  be  arranged  for  at  one  end  of  the  room,  a  capacious  sink  with  a  good 
supply  of  hot  and  cold  water  being  provided.  Next  to  this  is  placed  a 
washing  tank,  then  a  fixing  tank  or  tanks,  and  lastly  another  washing  tank. 
These  should  all  be  large  and  deep.  A  drying  rack  should  be  placed  at  this 
end  of  the  room,  and  a  viewing-box  for  inspection  of  the  negatives  when 
wet.  Plates  and  papers  should  be  kept  in  a  cupboard  at  the  opposite  end 
of  the  room,  if  an  outer  dark  room  has  not  been  provided. 

In  the  largest  hospitals  the  organisation  of  the  electrical  department 
becomes  more  involved.     It  is  only  when  the  whole  department  is  under 


86 


RADIOGEAPHY 


efficient  control  that  good  work  can  be  turned  out  in  a  routine  manner. 
The  efficiency,  therefore,  of  such  departments  depends  on  thorough  organisa- 
tion more  than  on  individual  effort.     All  the  workers  must  be  trained  to 


:^ 


Fig.    82.  —Plans  of  the  electrical  department  at  the  Cancer  Hospital,  Fulham. 
(By  kind  permission  of  E.  M.  Pole,  Esq.) 

perform  their  particular  part  of  the  general  whole  in  the  most  efficient  manner 
possible. 


X-RAYS  IN  MILITARY  SERVICE  87 


4.  Installation  for  a  Hospital  for  Military  Service 

Equipment  for  Military  Radiography.  —  Radiography  has  been 
found  to  be  of  great  use  in  the  detection  of  fractures  and  foreign  bodies. 
Its  value  therefore  in  the  medical  equipment  of  the  military  service  is 
beyond  doubt.  Thorough  equipment  and  organisation  are  necessary  to 
obtain  the  maximum  value,  as  it  is  often  a  matter  of  great  difficulty 
to  deal  in  the  most  efficient  manner  wdth  the  large  amount  of  work  which 
at  times  presents  itself.  The  ideal  scheme  is  one  which  is  simple,  com- 
prehensive, and  efficient,  and  this  entails  much  prehminary  detail  work. 
An  efficient  scheme,  and  one  which  commends  itself,  consists  of :  (1)  An 
installation  at  a  base  hospital,  (2)  a  serviceable  installation  at  a  collecting 
hospital,  (3)  a  portable  outfit  for  use  on  the  field. 

(1)  The  equipment  at  the  base  hospital  should  be  complete  in  every 
detail,  because  it  is  here  that  very  important  work  must  be  thoroughly  and 
expeditiously  carried  out. 

The  question  of  staff  depends  on  the  amount  of  work  required,  but  the 
equipment  suitable  for  a  general  hospital  is  suitable  for  such  a  base  hospital. 
The  advantages  of  a  thorough  equipment  are  other  than  purely  radiographic, 
as  it  can  be  used  as  a  training  school  where  medical  men,  nurses,  and  orderHes 
can  receive  appropriate  instruction  in  all  branches  of  the  work.  Also  it  is 
here  that  cases  requiring  very  careful  investigation  and  exact  localisation 
can  be  referred  from  the  collecting  centre. 

(2)  The  Collecting  Hospital. — This  outfit  should  be  more  or  less  a 
stationary  one,  with  ample  conveniences  for  photographic  work  ;  but  at  the 
same  time  the  apparatus  should  be  arranged  to  allow  of  quick  transport 
from  place  to  place  when  the  forces  are  moving  rapidly. 

The  following  apparatus  should  place  a  useful  outfit  in  the  hands  of  the 
radiographer:  (1)  Electrical  Supply.  To  obtain  the  necessary  electrical  supply 
the  choice  lies  between  (a)  accumulators  and  (6)  petrol  engine  and  dynamo. 
The  latter  is  undoubtedly  the  better,  though  it  is  a  good  plan  to  include  a  set 
of  accumulators  which  can  be  charged  from  the  dynamo.  The  petrol  engine 
and  dynamo  are  mounted  on  a  combination  bed-plate  ;  a  magneto  ignition 
carburettor  fuel  tank  and  radiator  should  form  part  of  the  set.  At  a  speed 
of  700  revolutions  per  second  the  apparatus  should  generate  1  kilowatt  or  100 
volts  and  10  amperes.  The  whole  should  be  completed  with  shunt  regulator 
switch-board  for  charging  accumulators,  and  there  should  be  a  radiator  for 
cooling  purposes.  This  set  should  be  arranged  for  direct  connection  to  the 
X-ray  apparatus.  (2)  A  set  of  portable  accumulator  batteries  consisting  of  six 
cells  and  50  ampere-hour  output.  (3)  A  12-  or  preferably  a  15-inch  portable 
coil  with  subdivided  primary  with  a  condenser  and  a  small  moto-magnetic 
interrupter ;  this  will  be  found  useful  as  a  second  break  when  the  larger 
one  is  out  of  action.  The  coil  should  be  fitted  into  a  strong  outer  wooden 
case  for  transport.  (4)  The  interrupter  should  be  of  good  size,  and  one  of  the 
many  mercury  jet  interrupters  will  be  most  suitable.     The  motor  should  be 


KADIOGEAPHY 


wound  to  work  at  100  volts  on  direct  current,  which  is  derived  from  the  petrol 
electric  set.  (5)  A  small  switch-board  and  rheostat  with  the  auxiliary  control 
switches  should  be  included.  This  may  be  arranged  in  the  form  of  a  box, 
which,  when  closed,  allows  of  ready  transport.  (6)  A  simple  tube-stand  with 
mechanical  movements  is  necessary.  It  should  be  readily  taken  to  pieces 
if  required.  (7)  An  X-ray  couch.  This  should  have  folding  legs,  and  should 
be  light  and  fairly  rigid.  It  should  be  constructed  so  as  to  allow  of  screening. 
(8)  X-ray  and  valve  tubes.  It  is  well  to  have  a  good  supply  of  these.  When 
it  is  necessary  to  have  the  installation  removed  to  another  base  they  should  be 
packed  in  large  boxes,  and  should  be  suspended  from  the  top  or  sides  of  the 
box  so  that  they  may  not  easily  be  broken  in  transit.  Three  to  six  tubes 
will  form  a  good  set  for  ordinary  use.     (9)  A  fluorescent  screen  fitted  with 


Interrupter 


Battery  Coil  in  cabinet 

Fig.  83. — Portable  X-ray  installation  arranged  for  radiography  from  beneath  couch. 

lead  glass  and  protective  rubber  handles.  Also  several  pairs  of  lead-lined 
gloves  will  be  necessary.  (10)  Intensifying  screens  with  casettes.  A  simple 
form  of  localiser  should  be  included.  Photographic  conveniences  :  these 
must  be  left  to  the  calls  of  the  particular  place  the  installation  has  to  serve. 
When  a  dark  room  is  not  available  it  must  be  provided  for.  A  small  dark 
room  may  be  constructed  of  wood  built  in  sections,  or  a  tent  may  be  requisi- 
tioned. The  fittings  should  consist  of  lead-hned  benches,  with  sink  and 
waste  pipe.  A  water-supply  can  be  connected  to  the  sink  if  such  is  available. 
A  good  supply  of  flexible  tubing  will  be  found  useful  when  water  has  to  be 
brought  from  a  distance.  A  dark-room  lamp  with  a  safe  light  should  be 
included.  A  candle  will  give  sufficient  illumination.  (11)  Developing 
dishes  of  sizes  up  to  12  inches  by  14  inches,  also  draining  racks,  etc.  (12)  A 
supply  of  X-ray  plates  and  X-ray  paper.     The  latter  is  useful  when  it  is  not 


PORTABLE  FIELD   OUTFIT 


89 


convenient  to  use  plates.  An  X-ray  paper  for  direct  radiography  has  been 
prepared.  This,  though  not  so  good  as  the  plate,  is  much  more  convenient 
for  transport.  (13)  A  supply  of  chemicals.  The  tabloid  developers  are  very 
useful,  as  they  are  readily  made  up  in  a  few  minutes.  The  installation  may 
be  varied  according  to  the  needs  of  the  radiographer,  the  important  point 
being  to  provide  a  high  standard  of  efficiency,  combined  with  the  possibility 
of  rapid  movement  if  such  be  required.  The  efficiency  will  depend  upon  the 
knowledge  the  operator  has  of  his  apparatus.  He  should  be  conversant  with 
the  mechanical  details  of  all  parts,  and  should  be  able  to  pack,  re-install,  and 
get  into  working  order  quickly.     Practice  wdll  soon  enable  him  to  do  all  that 


'-^. 


Fig.  84. — Portable  X-ray  installation  packed  ready  for  transit  (Medical  Supply  Association). 


is  necessary.  When  a  large  amount  of  work  has  to  be  done,  assistance  must 
be  available.  One  or  more  medical  radiographers  should  accompany  each 
installation,  and  several  orderlies  or  nurses  must  be  trained  to  carry  on  the 
work  at  any  time. 

In  the  case  of  large  armies  there  must  necessarily  be  several  installations 
working  at  various  places.  To  facilitate  rapid  work  a  system  must  be 
employed. 

The  difficult  cases  may  be  transferred  to  the  hospitals  at  home  if  the 
patient  is  in  a  condition  to  travel  and  the  symptoms  are  not  urgent.  By 
doing  this  the  collecting  hospitals  are  reheved  of  heavy  work,  involving 
much  time,  and  are  able  to  attend  to  the  more  urgent  cases  as  they 
come  in. 


90  EADIOGEAPHY 

For  localisation  of  foreign  bodies  several  methods  may  be  used ;  these 
are  fully  described  in  the  portion  of  the  book  dealing  with  localisation. 

(3)  The  Field  Outfit. — The  essential  is  portability.  The  best  arrange- 
ment for  work  on  the  field  is  a  small  but  serviceable  installation  fitted  up  in  a 
motor  transport,  the  engine  of  which  can  be  used  to  drive  the  dynamo  which 
generates  the  electricity.  By  this  means  a  more  powerful  installation  can 
be  used  than  when  dealing  with  accumulators.  The  whole  apparatus  can 
be  fitted  up  in  a  motor  bus,  a  portion  of  which  can  be  screened  of?  to  form 
a  small  dark  room. 

Necessary  Apparatus.  —  (1)  A  dynamo,  (2)  mercury  jet  interrupter, 
(3)  fifteen-inch  coil,  (4)  X-ray  couch  with  all  accessories,  (5)  tube-stand 
with  mechanical  movements,  (6)  fluoroscope  for  screening,  (7)  plates,  tubes, 
and  dark-room  requisites. 

An  extremely  compact  and  portable  outfit  is  illustrated  on  pages  88 
and  89.  It  is  most  suitable  for  field  work  when  petrol  engine  and  dynamo 
are  not  available.  It  combines  portability  with  considerable  efficiency. 
It  consists  of  : 

(a)  Set  of  accumulators. 

(6)  Hand-driven  interrupter,  which  controls  the  current  derived  from 
the  accumulators. 

The  method  used  for  obtaining  the  required  speed  from  the  interrupters 
is  somewhat  ingenious,  a  cylindrical  weight  inside  the  interrupter  giving  the 
effect  of  a  fly-wheel,  and  permitting  a  regular  speed  to  be  obtained. 

(c)  Coil  enclosed  in  a  cabinet  which  is  arranged  to  form  a  complete  case 
for  the  whole  outfit. 

(d)  Tube-holder  combined  with  the  cabinet. 

The  small  portable  set  when  not  in  use  for  field  work  may  be  used  for 
radiography  of  cases  in  the  wards  of  the  hospital.  There  are  many  patients 
who  are  not  fit  to  be  moved  to  the  radiographic  room ;  such  cases  can  con- 
veniently be  done  in  bed  when  a  portable  set  is  available. 


PRODUCTION  OF  THE  RADIOGRAPH 

The  question  of  exposure  in  radiography  is  one  which  is  ever  before  us. 
How  long  an  exposure  must  we  give  for  a  particular  region  ?  Before  making 
a  statement  on  the  question  of  time  it  is  necessary  to  consider  the  various 
factors  which  govern  the  exposure. 

The  Plate  or  Film  Employed 

This  is  the  first  point  for  consideration.  X-ray  plates  are  specially 
prepared  for  radiographic  Avork,  and  any  of  those  on  the  market  are 
good.  In  this  country  the  most  suitable  and  best  know^n  are  those  of 
Ilford,  Wellington,  Warwick,  Wratten,  and  the  Barnet.  The  emulsion  is 
spread  over  a  sheet  of  glass,  and  the  plate  is  enclosed  in  two  light-tight 
envelopes.  A  second  envelope  is  used  to  avoid  the  danger  of  fogging  when 
one  only  is  employed,  by  accidental  admission  of  light  or  through  pin  holes 
in  the  paper. 

These  special  X-ray  plates  are  expensive,  so  when  a  large  amount  of 
work  has  to  be  got  through,  a  cheaper  plate  may  be  used  for  the  detection 
of  fractures  of  the  extremities.  When  a  fine  detail  is  not  essential,  as  in 
determining  the  presence  of  a  fracture  or  dislocation,  any  ordinary  photo- 
graphic plate  can  be  used.  The  plate  may  be  placed  in  a  special  casette,  in 
which  case  the  black  envelopes  are  not  required.  Care  must  be  exercised  in 
the  dark  room,  when  opening  a  box  to  take  out  a  plate,  to  make  sure  that 
the  light  is  "  safe." 

When  the  dark  room  is  in  close  proximity  to  the  radiographic  room, 
some  form  of  protection  must  be  employed  to  prevent  the  plates  from  being 
fogged  by  X-rays.  A  box  lined  w-ith  several  millimetres  of  lead  will  be 
sufficient  to  serve  for  the  protection  of  these. 

Manufacturers  are  endeavouring  to  produce  a  plate  which  will  be  much 
faster  than  those  at  present  in  use. 

Exposure 

The  length  of  the  exposure  depends  upon  : 

(1)  The  quality  of  the  tube  and  the  degree  of  penetration. 

(2)  The  strength  of  the  current  employed,  the  size  and  quahty  of  the 
coil,  and  the  type  and  frequency  of  the  interrupter. 

91 


92  EADIOGRAPHY 

(3)  The  thickness  of  the  object. 

(4)  The  distance  of  the  tube  from  the  plate. 

(5)  The  rapidity  of  the  X-ray  plate. 

The  Quality  of  the  Tube. — The  operator  must  know  the  quality  of 
his  tubes  well,  A  hard  tube  should  rarely  be  used  if  good  radiographs  are 
required.  A  soft  tube  will  give  good  detail  in  all  the  parts,  but  particularly 
of  the  soft  parts,  where  a  diagnosis  is  required  of  their  condition.  For  fine 
detail  in  bones  it  is  better  to  give  long  exposures  with  a  soft  tube,  and  trust 
to  the  increase  in  the  time  to  give  the  necessary  detail. 

The  Intensity  of  the  X-rays  is  in  proportion  to  the  penetrating 
power  of  the  tube  multiplied  by  the  number  of  milliamperes  used.  With 
one  and  the  same  tube,  1  milUampere  for  60  seconds,  or  2  milhamperes 
for  30  seconds,  or  10  milliamperes  for  6  seconds  will  produce  the  same  effect 
on  a  plate.  If  tubes  of  different  penetrating  power  are  used,  the  number 
of  milliampere-seconds  required  with  a  soft  tube  may  be  three  to  five  times 
as  great  as  that  required  with  a  hard  one.  To  produce  a  certain  density  on 
a  plate,  30  seconds'  exposure  with  a  current  of  2  milliamperes  may  be 
sufficient  with  a  hard  tube,  whereas  with  a  soft  one  either  150  seconds  may 
have  to  be  given  with  a  current  of  2  milhamperes,  or  else  30  seconds 
with  a  current  of  10  milhamperes. 

The  next  factor  in  the  calculation  of  the  exposure  is  the  thickness  of 
the  subject.  Chest  and  abdomen,  for  instance,  may  have  the  same  thick- 
ness, but  if  the  latter  requires  200  milliampere-seconds,  50  to  80  milliampere- 
seconds  may  be  enough  for  the  former,  because  the  chest  contains  the 
lungs  filled  with  air,  whereas  the  contents  of  the  abdomen  have  a  greater 
atomic  weight.  For  the  same  reason  the  head  requires  more  milliampere- 
seconds  than  the  chest,  though  both  may  have  the  same  thickness.  The 
intensity  of  the  X-rays  is  in  inverse  proportion  to  the  square  of  the 
distance.  While  one  is  aware  that  any  increase  of  distance  means 
prolongation  of  the  exposure,  it  is  a  good  point  to  get  a  good  distance 
away  from  the  plate.  The  farther  the  distance  between  the  anti-cathode 
and  the  plate  up  to  a  limit  of  about  6  feet  the  sharper  will  be  the  resulting 
radiograph.  At  the  distance  of  6  feet  a  natural-sized  picture  is  obtained, 
with  no  distortion.  This  distance  may  be  employed  when  the  exact  size 
of  an  organ  like  the  heart  is  desired  ;  a  good  average  working  distance  is 
about  2  feet  for  parts  of  average  thickness. 

A  slide  rule  enables  us  to  find  out  the  necessary  exposure  approximately. 
The  first  scale  contains  figures  for  the  distance  between  anti-cathode  and 
plate,  varying  from  12  up  to  200  cm.  On  the  second  scale,  figures  for  the 
thickness  of  the  object,  varying  from  2|  up  to  50  cm.,  will  be  found.  On 
the  third  scale  is  the  penetrating  power  of  the  tube  in  Wehnelt  units,  from 
2  up  to  18  ;  and  the  fourth  scale  contains  the  figures  for  the  milliamperes 
used,  and  rises  from  0-5  up  to  50  milliamperes. 

By  adjusting  the  two  slides  so  that  the  figures  for  the  distance,  thickness, 
penetration,  and  current  which  are  being  used  are  opposite  to  one  another, 
the  index  on  the  second  slide  points  to  the  number  of  seconds  required  for  the 


ESTIMATION   OF  THE  EXPOSURE 


93 


exposure,  which  is  on  the  fifth' scale,  beginning  with  I  and  rising  up  to  120 
seconds. 

On  this  basis  it  is  possible  to  set  down  an  Exposure  Table  which  shall  be 
of  some  practical  utility  to  the  beginner.  There  are  of  course  so  many 
special  conditions  that  come  into  the  matter  that  it  is  not  possible  to  lay 


SCHALL    »    SON 


Bjjr  Expocurts 

0  PLATS. IN  CTM. 

M  M  1!        10        5» 

f    •?     I    "    li?   I  »  I  : 


LCHSCK.  M. 


1 — I     ill','  ['i'l'!'l',i''",i'^''i-'^''J,'"'i '  i  '  i 


rrrr      ^^ 


J  '  1  'i'i4'i'riv"'i""i"'ri 'i'j'i' i'L'. 


EXPOSURE  IN   SECONDS 


Fig.  85.— Slide  rule. 

down  hard  and  fast  rules.  Actual  experience  with  the  outfit  and  tubes 
is  essential,  combined  with  the  exercise  of  good  judgment.  The  following 
table  will  therefore  only  be  taken  as  a  guide,  remembering  always  that 
if  the  tube  be  softer  or  the  distance  greater  the  exposure  must  be  corre- 
spondingly increased.  The  exposure  must  also  be  increased  for  abnormal 
stoutness,  and  so  on.  Above  all,  each  focus  tube,  no  matter  what  its  degree 
of  hardness,  must  be  worked  to  just  that  extent  which  signifies  maximum 
eflaciency,  neither  under-running  nor  overstraining.  This  point  is  dealt 
with  fully  in  the  chapter  on  Tubes. 


Object. 


Distance 
from  plate 
to  anti- 
cathode. 


Penetration. 


Wehnelt 
Scale. 


Benoist  and 
Bauer. 


M.A. 
Seconds. 


Skull,  occipito-frontal 
Skull,  transversely       .... 
Skull,  teeth  (with  film  inside)  . 
Cervical  vertebrae         .... 

Shoulder    .  

Thorax 

Lumbar  region 

Abdomen 

Ribs 

Knee-joint 

Femur 

Ankle  and  foot 

Wrist,  hand 

Stomach  (Bismuth  meal)    . 

Kidney  

Pelvis 

Hip-joint 

Heart 

Lungs,  diagnosis  of  early  tuberculosis 


Inches. 

18 

18 

15 

18 

18 

18 

18 
22-28 

22 

22 

18 

22 

18 

24 

18 

24 

24 

24 

22 


9-10 

6-7 

9-10 

6-7 

8 

5 

8-9 

5-6 

7-8 

5 

7-8 

5 

8-9 

5-6 

8-9 

5-6 

8-9 

5-6 

8 

5 

9 

6 

6-7 

4-5 

6 

4 

9-10 

6-7 

6-7 

4-5 

9-10 

6-7 

9-10 

6-7 

9 

6 

6-7 

4-5 

90 

140 

15 

70 

80 

80 

180 

75 

75 

70 

90 

30 

12 

100 

180 

200 

150 

45 

100 


The  above  exposures  are  calculated  without  intensifying  screen.     If  a 
screen  be  used,  the  exposures  are  reduced  to  about  x^th  or  y^th. 

Rapid  radiographs  in  one  or  two  seconds,  or  even  fractions  of  a  second, 


M 


RADIOGRAPHY 


are  secured  by  powerful  intensified  coils  of,  say,  16-inch  spark  length  running 
with  centrifugal  motor  mercury  interrupter,  utilising  a  heavy  primary  current, 
and  in  conjunction  with  a  good  heavy-anode  tube  that  has  been  well  tuned 
up.  After  practical  experience,  and  after  becoming  a  thorough  master  over 
the  peculiarities  of  his  own  outfit  and  his  own  focus  tubes,  the  beginner 
will  soon  find  that  he  is  able  to  reduce  exposures  very  considerably  all  round. 
With  a  single-impulse  apparatus  radiographs  of  the  chest  may  be 
obtained  when  an  intensifying  screen  is  used  in  y^  of  a  second.  The  more 
recent  forms  of  this  apparatus  enable  the  worker  to  obtain  good  radiographs 
of  stout  patients  in  this  time.  For  the  abdomen  the  output  of  the  apparatus 
is  not  sufficient  to  produce  good  results.  In  such  instances  recourse  must 
be  had  to  comparatively  short-time  exposures.  With  an  automatic  cut-out 
switch  tV  or  ^  of  a  second  may  then  be  sufficient.  The  aim  of  all  workers 
is  to  produce  instantaneous  radiographs  without  the  use  of  the  intensifying 
screen.  The  Coolidge  tube,  with  its  capacity  for  passing  heavy  discharges, 
jnay  be  a  means  to  this  end. 

ExposTJKE  Tables 
Comparison  of  Different  Radiometers 


Benoist  .... 

2 

2* 

3 

4 

5 

6 

7 

8 

9 

10 

Benoist-Walter     . 

1 

2 

3 

4 

4* 

5 

5^ 

6 

Walter   .... 

2-3 

3-4 

4-5 

5-6 

6 

6-7 

7 

7-8 

Wehnelt 

1-8 

3-3 

4-9 

6-5 

7-2 

8 

9 

10-5 

13 

15 

Bauer     .... 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

The  Intensity  of  the  X-rays  varies  with  the  Distance  between  Anti-cathode 
and  Plate  or  Object. — The  intensity  of  the  X-rays  is  in  inverse  proportion  to 
the  square  of  the  distance.  If  we  have  to  expose  for  a  certain  object  3 
.seconds,  with  a  distance  of  10  inches  between  the  anti-cathode  and  the  plate, 
the  time  of  exposure  required  with 


will  be 


10       12         16      20       25        30    40    50       60       80  inches 
3     4-32      7-68     12     18-75     27     48     75     108     192  seconds 


■or,  expressed  in  other  figures 


Distance 
Exposure 


10 
10 


14-1 
20 


17-3 
30 


20 
40 


22-4 

50 


24-5 
60 


26-4 

70 


28-3 
80 


30  cm. 

90  M.A.  seconds. 


'The  distances  usually  chosen  are  : 

For  teeth,  toes,  fingers,  or  hands 
Arms,  neck,  leg,  or  foot 
Nose,  head,  shoulder,  knee     . 
Chest,  kidney,  pelvis    . 


10  to  12 
12  „  15 
20  „  22 

22  „  25 


inches. 


The  distances  given  are  approximate  only.  When  the  subject  is  fairly 
thick,  it  may  be  necessary  to  have  the  tube  at  a  greater  distance ;  also, 
when  the  object  from  a  diagnostic  point  of  view  is  likely  to  be  obscured  by 
shadows  thrown  by  structures  in  front  of  it,  it  will  be  found  advantageous 
to  have  the  tube  close  to  the  surface  of  the  body. 


PHOTOGRAPHIC  TECHNIQUE  95 

Caution 

The  distance  chosen  depends  upon  the  thickness  of  the  subject.  At  the 
longer  distances  we  must  employ  apparatus  of  varying  power,  such  as  an 
intense  single-impulse  coil,  or  one  of  the  forms  of  high-tension  rectifier. 

The  additional  advantage  of  working  at  long  distances  from  the  tube 
is  that  both  the  patient  and  the  person  screening  are  less  likely  to  be  damaged 
by  the  X-rays. 

Care  must  be  increased  when  working  at  a  short  distance,  especially 
when  repeated  examinations  of  a  particular  patient  are  required,  that  the 
patient  is  not  damaged.  If  work  must  be  done  at  a  close  range  it  is  wise  to 
have  in  front  of  the  tube  a  screen  of  aluminium  1  mm.  thick.  This  does  not 
cut  oii  any  of  the  penetrating  rays,  but  retards  the  softer  ones,  which  are 
likely  to  damage  the  skin. 

The  exposure  times  given  on  page  94  are  only  approximate,  and  should 
not  be  taken  as  an  absolute  guide.  They  illustrate  the  principle  of  exposures 
rather  than  the  practice.  Conditions  vary  with  different  apparatus,  conse- 
quently the  operator  must  clearly  understand  his  outfit,  particularly  the 
X-ray  tube.  When  very  rapid  exposures  have  to  be  made  the  difficulty  of 
accurate  work  is  increased,  there  being  no  great  latitude  upon  which  to  work. 
Single-impulse  exposures,  when  an  intensifying  screen  is  used,  are  com- 
paratively easy,  but  even  here  the  correct  condition  of  the  tube  must  be 
obtained  if  perfect  radiographs  have  to  be  produced.  A  tube  a  trifle  too  hard 
will  give  an  over-exposure,  while  a  soft  tube  will  give  an  under-exposure. 
It  is  possible  that  when  tubes  constructed  on  the  principle  of  the  Coolidge 
tube  come  into  general  use,  the  technique  of  exposure  will  require  to  be 
largely  remodelled. 

The  Adjustment  of  the  Radiographic  Plate 

For  X-ray  examinations  a  special  plate  is  employed.  It  is  made  more 
sensitive,  and  gives  greater  detail  by  reason  of  a  thicker  emulsion,  containing 
more  silver  salt  than  the  ordinary  photographic  plate. 

The  plate  is  placed  in  a  casette  or  two  light-proof  envelopes  in  the  dark 
room,  the  film  side  of  the  plate  being  placed  towards  the  object  to  be  radio- 
graphed. 

The  centering  of  the  plate  is  a  matter  of  some  importance,  most  modern 
couches  having  devices  by  which  this  may  be  done  automatically.  The 
best  method  of  centering  is  one  devised  by  Dr.  Ironside  Bruce,  where  the 
central  ray  from  the  tube  can  always  be  located  by  means  of  a  plumb-line 
operating  over  the  top  of  the  couch.  This  may  also  be  used  for  getting  the 
centre  of  the  plate  exactly  in  the  centre  of  the  part  to  be  examined. 

The  part  of  the  patient  to  be  examined  should  always  be  as  close  to 
the  plate  as  possible.  On  the  couch  some  form  of  compression  must  be 
employed  to  keep  the  parts  as  quiet  as  possible.  When  the  screening-stand 
is  used,  the  part  is  first  examined  by  the  aid  of  the  fluorescent  screen,  and 


96 


EADIOGRAPHY 


the  diaphragm  adjusted  to  cover  the  part  required.  The  fluorescent  screen 
is  replaced  by  the  X-ray  plate  in  a  casette  and  clamped  in  position,  and  the 
patient  may  be  fixed  by  a  strong  linen  band  or  a  bandage.  The  shorter  the 
exposure  the  less  risk  is  there  of  movement  on  the  part  of  the  patient  spoiling 
the  result. 

The  Use  of  the  Intensifying  Screen 

Though  negatives  obtained  by  the  use  of  the  intensifying  screen  may 
not  perhaps  be  of  the  same  high  technical  quality  as  the  best  radiographs 


Fig.  86. — Normal  hand  to  illustrate  value  of  an  intensifying  screen. 
(a)  An  intensifying  screen  was  used  for  this  (b)  Taken  without  an  intensifying  screen  with  ten 


radiograph,  the  exposure  being  yV  "^f  that  for  (b). 
The  radiogTaph  was  considerably  over-exposed. 


times  the  exposure.    Note  the  detail  in  soft  parts. 


made  by  powerful  installations  without  a  screen,  it  should  be  noted  that 
when  skilfully  used,  pictures  so  obtained  with  apparatus  of  moderate  power 
are,  from  a  diagnostic  point  of  view,  of  much  greater  value  than  those 
obtained  without  a  screen.  This  is  especially  the  case  when  radiographing 
parts  of  the  body  where  movements  are  constantly  going  on,  as  in  the  chest 
and  abdomen.  The  plate  must  not  be  over-exposed,  otherwise  grain,  due 
to  contact  with  the  screen,  is  bound  to  appear.  A  soft  tube  also  is  necessary 
when  the  screen  is  used,  and  it  should  be  noted  that  there  is  not  quite  the 
same  degree  of  latitude  in  the  matter  of  exposure,  but  when  all  conditions 
are  correct,  radiographs  so  obtained  can  hardly  be  distinguished  from  those 
taken  without  the  aid  of  the  intensifying  screen.  This  applies  not  only  to 
the  plate,  but  more  particularly  to  the  print,  and  a  little  experience  with  an 


DEVELOPMENT  OF  THE   PLATE  97 

average  installation  of  moderate  power  and  a  screen  will  soon  teach  anyone 
how  to  obtain  valuable  diagnostic  negatives,  and  enable  the  operator  to  do 
quick  work,  which  would  otherwise  be  beyond  his  reach. 

For  the  purposes  of  diagnosis  in  regions  such  as  the  heart,  lungs,  stomach, 
or  intestines,  the  value  of  radiographs  so  obtained  cannot  be  overestimated, 
as  with  any  of  the  modern  intensifying  screens  it  is  quite  possible  to  get 
results  showing  practically  no  grain. 

It  is  most  important  that  every  care  should  be  taken  to  avoid  damage 
to  the  delicate  surface  of  the  screen,  because  any  scratches  or  other  markings 
causing  an  abrasion  of  the  surface  will  certainly  be  produced  on  the  negatives. 

Before  placing  the  screen  in  the  holder  it  should  be  carefully  dusted 
with  a  wide  camel-hair  brush.  The  film  side  of  the  plate  is  brought  into 
contact  with  the  fluorescent  coating  on  the  screen,  care  being  taken  to  avoid 
rubbing  the  surfaces  together.  When  making  the  exposure  the  film  side  of 
the  plate  should  face  the  X-ray  tube.  When  the  screen  is  not  in  use  it  should 
be  placed  in  such  a  position  that  it  cannot  get  damaged  or  splashed  with 
chemicals.  The  value  of  an  intensifying  screen  is  illustrated  by  the  figures 
on  the  opposite  page. 


Development 

The  general  description  of  the  dark  room  has  been  given  in  the  chapter 
on  the  arrangement  of  apparatus,  etc.  It  is  essential  to  take  the  same  care 
in  the  development  of  X-ray  plates  as  is  necessary  in  developing  the  fastest 
of  ordinary  photographic  plates. 

Specially  prepared  X-ray  plates  are  slightly  sensitive  to  red  light,  and 
care  must,  therefore,  be  taken  to  avoid  more  light  falling  on  the  plate  during 
development  than  is  really  necessary.  This  can  be  accomphshed  in  the 
following  ways  : 

1.  The  employment  of  a  carefully  tested  "  safe-light "  glass  in  front 
of  the  source  of  illumination.  This  screen  must  be  tested  in  the  conditions 
under  which  it  will  work  ;  thus,  if  electric  light  is  used,  a  bulb  of  the  same 
candle-power  should  always  be  used  in  the  lamp. 

2.  The  electric  bulb  may  be  immersed  in  a  solution  coloured  by  bichrom- 
ate of  potash  and  an  aniline  dye.  To  ensure  greater  safety  the  globe  con- 
taining the  lamp  should  be  covered  with  a  layer  of  yellow  and  ruby  fabric. 
Provided  exposure  is  not  unduly  prolonged,  the  X-ray  plates  may  be 
developed  in  this  light.  The  dark  room  lamp  should  have  in  a  convenient 
place  a  switch  in  order  that  the  light  may  be  turned  off  when  developing  the 
plate. 

3.  A  cover  to  fit  the  developing  dish  may  be  placed  over  it  immediately 
the  plate  is  immersed,  and  not  removed  for  several  minutes,  as  it  is  in  the 
early  stages  of  development  that  plates  are  most  easily  fogged. 

4.  The  plate  may  be  developed  in  the  dark. 

The  Choice  of  a  Developer. — Any  properly  balanced  developer  can 

7 


98  EADIOGEAPHY 

be  used,  the  majority  of  workers  using  that  recommended  by  the  makers  of 
the  plates.  Of  these  (1)  Metol-hydrokinone,  (2)  glycine,  (3)  rodinol,  (4) 
pyro-soda  are  the  most  commonly  used,  and  each  has  its  own  advocate. 
The  formula  for  one  of  the  most  largely  used — ^metol-hydroldnone — is  : — 
Metol,  20  grains ;  hydrokinone,  80  grains ;  sodii  sulphite  (crystals),  2 
oz. ;  sodii  carbonate  (crystals),  2  oz.  ;  potassii  bromide  solution  (10  per 
cent.),  80  minims  ;  water,  20  oz. 

The  Preparation  of  the  Developer. — (1)  The  metol  must  first  be 
dissolved  in  8  ounces  of  pure  water  (warm).  When  thoroughly  dissolved 
the  hydrokinone  is  added. 

(2)  The  sodas  and  bromide  are  then  dissolved  in  a  further  8  ounces 
of  warm  water,  the  two  solutions  mixed,  and  made  up  to  20  ounces. 

It  is  most  important  that  each  ingredient  be  allowed  to  dissolve 
thoroughly  before  the  next  is  added.  The  developer  is  then  allowed  to  cool, 
and  to  ensure  the  best  results,  should  be  used  at  a  temperature  of  60°  F. 
The  following  facts  explain  the  reason  for  this  insistence  on  a  imiform  tem- 
perature :  Metol  and  hydrokinone  act  differently  on  the  photographic 
plate,  metol  being  employed  to  obtain  good  detail,  while  the  hydrokinone 
ensures  density.  The  hydrokinone  acts  best  at  a  temperature  of  about 
65°,  and  becomes  practically  inert  below  45°,  and,  therefore,  in  order  to  ensure 
that  both  agents  act  to  the  best  advantage,  it  is  necessary  to  work  at  about 
60°.  For  this  reason  in  cold  weather  the  dark  room  should  be  kept  at  a 
little  above  60°,  and  at  a  level  temperature,  in  order  that  the  dishes  and 
solutions  should  not  fall  much  below.  In  very  cold  weather,  when  plates 
are  obtained  which  are  lacking  in  density,  but  show  fine  detail, — when  all 
other  factors  employed  in  the  exposure  of  the  plate  have  been  favourable, 
and  a  good  strong  negative  was  expected — the  explanation  is  often  found  to 
be  a  faulty  temperature  of  the  developer. 

Caution. — ^If  the  metol  is  not  allowed  to  dissolve  thoroughly  before 
the  other  chemicals  are  added,  it  will  crystalhse,  and  be  precipitated  in  the 
form  of  granules.  Should  any  of  these  settle  on  the  plate  during  the  process 
of  development,  small  black  spots  with  soft  edges  are  Hkely  to  appear  in 
those  places  where  the  granules  have  settled.  Moreover,  in  using  the 
developer  improperly  made  up,  the  full  strength  is  not  available,  and  such 
conditions  may  account  for  failure  to  obtain  the  best  possible  results.  A 
freshly  made  developer  should  be  almost  transparent  in  appearance  and 
free  from  colour  ;  stale  developer  is  from  a  light-  to  a  dark-brown  in  colour. 
In  hospitals  and  similar  institutions,  and  with  many  radiographers,  the 
practice  is  to  have  the  developer  made  up  by  the  chemist  or  his  assistant, 
who  does  not  understand  the  importance  of  extreme  purity  of  chemicals 
and  exact  weighing,  and  so  frequently  sends  up  a  hastily  prepared  developer 
which  may  spoil  many  otherwise  good  results.  In  large  institutions  a 
skilled  photographer  should  be  attached  to  the  department,  whose  duty  it 
should  be  to  attend  to  the  preparation  of  all  solutions  used. 

When  specially  good  negatives  are  desired  it  is  a  good  plan  to  have  a 
stock  solution  of  sodium  sulphite  and  carbonate  in  the  proper  proportions 


FIXATION   OF  THE   DEVELOPED   PLATE  99 

ready  at  hand.  The  metol  and  hydrokinone  are  then  freshly  prepared  in 
warm  water  when  wanted,  and  added  as  required,  as  is  also  the  bromide 
solution.  If  these  points  are  attended  to,  there  should  be  no  difficulty  in 
obtaining  really  first-class  negatives.  The  developing  solution  should  not 
be  used  for  more  than  three  or  four  plates  in  succession  ;  if  used  too  often 
it  becomes  oxidised  by  exposure  to  the  air,  and  ceases  to  yield  satisfactory 
results. 

A  developer  which  has  already  been  used  for  a  number  of  plates  should 
not  be  kept  for  further  use.  Oxidation  having  commenced  A\ill  continue  until 
the  solution  ultimately  becomes  nearly  black  and  quite  useless.  The  freshly 
made  metol  and  hydrokinone,  if  kept  in  properly  stoppered  bottles,  will 
keep  in  good  condition  for  a  considerable  time. 

With  normal  exposures  the  image  appears  in  about  fifteen  seconds, 
and  development  is  complete  in  four  to  five  minutes  ;  but  in  cases  where 
the  exposure  has  been  very  short,  the  image  appears  more  slowly,  and  the 
time  of  development  is  proportionately  longer.  Where  instantaneous 
exposures  have  been  given,  such,  for  instance,  as  j}q  of  a  second,  development 
from  fifteen  to  twenty  minutes  may  be  necessary  in  order  to  secure  the 
desired  results.  Under  these  circumstances  it  is  advisable  to  keep  the 
developing  dish  covered  over  in  order  to  avoid  any  possibility  of  fog  from 
prolonged  exposure  to  the  dark  room  light  during  the  process  of  development ; 
and  the  dish  should  be  gently  rocked  until  development  is  complete.  The 
use  of  a  weak  or  highly  restrained  developer  should  be  avoided. 

Fixing 

After  development  the  plate  should  be  rinsed  for  at  least  thirty  seconds 
before  placing  in  the  following  fixing-bath  : 

Hyposulphite  of  soda,  1  lb.  ;  potassium  metabisulphite,  |  oz.  ;  water 
to  80  oz. 

If  the  fixing-bath  is  required  for  immediate  use  it  is  advisable  to  dissolve 
the  potassium  metabisulphite  before  adding  the  hypo,  but  hot  water  should 
not  be  used  for  the  purpose. 

Allow  the  negative  to  remain  in  the  hypo  bath  until  thoroughly  fixed, 
and  on  no  account  examine  a  partially  fixed  plate  by  daylight,  or  stains  will 
appear  on  the  fUm  which  cannot  afterwards  be  washed  out. 

If  the  plate  is  not  washed  free  from  developer  before  being  placed  in 
the  fixing-bath,  yellow  stains  will  appear  on  the  film  which  are  very  difl&cult 
to  remove. 


Washing  and  Drying 

After  complete  fixation,  the  plate  should  be  washed  in  running  water 
for  at  least  one  hour,  and  then  placed  in  a  well-ventilated  room,  free  from 
dust,  until  dry.  If  a  negative  is  required  for  use  immediately  after  develop- 
ment, fixing,  and  washing,  it  may  be  dried  rapidly  by  the  following  method  : 


100  EADIOGRAPHY 

The  surface  moisture  is  first  removed  by  allowing  the  plate  to  drain, 
or  it  may  be  carefully  removed  mth  a  wad  of  cotton-wool  or  a  pad  of  fine 
chamois  leather.  It  is  then  placed  in  a  methylated  spirit  bath  for  four  or 
five  minutes,  and  rocked  as  in  development.  It  is  then  removed,  and 
placed  in  a  current  of  air  or  in  front  of  an  electric  fan,  when  it  will  dry  very 
rapidly,  or  it  may  be  placed  in  a  specially  arranged  drying-oven. 

Reduction 

It  is  sometimes  necessary  to  reduce  a  developed  plate  which  has  been 
made  too  dense.  The  following  solution  will  be  found  very  useful  for  the 
purpose  :  Potassium  ferricyanide,  120  grains  ;  water  to  20  oz.  A  dram  or 
two  of  this  is  added,  just  before  using,  to  each  ounce  of  ordinary  hypo  solu- 
tion as  used  for  fixing  photographic  plates,  i.e.  hypo,  4  oz.  ;  water  to  20  oz. 
The  plate  is  immersed  in  the  reducer  when  it  is  to  be  acted  on  all  over,  or  if 
for  local  use,  the  solution  is  apphed  with  a  httle  tuft  of  cotton- wool.  The 
plate  after  reduction  is  well  washed  and  dried. 

Intensification 

Negatives  which  are  not  sufiiciently  \dgorous  omng  to  some  error  in 
manipulation  may  be  greatly  improved  by  the  process  of  intensification. 
The  film  should  first  be  hardened  in  the  following  bath  :  Formalin,  1  part ; 
water,  10  parts.  In  this  bath  the  negative  should  be  allowed  to  remain  for 
five  minutes,  after  which  it  should  be  rinsed  for  a  few  nnnutes,  and  then 
placed  for  exactly  one  minute  in  the  following  bath  :  Potassium  ferricyanide, 
20  grains  ;  potassium  bromide,  20  grains  ;   water  to  20  oz. 

Too  long  an  immersion  causes  the  image  to  bleach,  and  this  should  be 
avoided  if  it  is  desired  to  retain  the  original  gradation.  In  the  time  pre- 
scribed there  is  no  apparent  change,  but  the  clearing  agent  has  done  its  work, 
which  is  the  prevention  of  green  fog  in  the  subsequent  process  of  intensi- 
fication. The  negative  should  now  be  rinsed  for  a  few  minutes,  and  then 
intensified  in  the  following  stock  solutions  : 

{a)  Silver  nitrate,  800  grains  ;   distilled  water  to  20  oz. 

(b)  Ammonium  sulphocyanide,  1400  grains  ;  hypo,  1400  grains  ;  water 
to  20  oz. 

Half  an  ounce  of  {a)  should  be  taken  and  added  slowly  to  half  an  omice  of 
(6),  stirring  vigorously  with  a  glass  rod.  Sufficient  silver  nitrate  solution 
must  be  added  until  the  precipitate  formed  is  dissolved  with  difiiculty. 
To  this  solution  should  be  added  :  1  dram  of  a  10  per  cent,  solution  of  pyro 
preserved  with  sulphite,  2  drams  of  a  10  per  cent,  solution  of  ammonia. 

The  negative  should  be  placed  in  a  chemically  clean  dish,  and  the  silver 
nitrate  solution  poured  over  it.  In  a  minute  or  two  the  deposition  of  the 
silver  begins  to  take  place,  and  as  soon  as  sufficient  density  has  been  acquired, 
the  negative  should  be  placed  in  an  acid  fixing-bath  until  the  slight  pyro 
stain  is  removed.     After  this  bath  the  negative  should  be  well  washed,  it 


PRINTING  FROM  THE   NEGATIVE  101 

being  well,  during  washing,  to  lightly  rub  the  surface  of  the  film  with  a  tuft  of 
cotton  wool  to  remove  the  slight  surface  deposit  which  will  be  found  upon  it. 
It  is  important  that  the  negative  to  be  intensified  must  have  been  thoroughly 
fixed  in  a  clean,  fresh  hypo  bath,  and  not  merely  have  been  left  for  some 
indefinite  period  in  a  stale  or  dirty  solution  of  hypo  that  has  been  used 
on  other  occasions.  A  useful  method  is  to  bleach  the  washed  negative  in  a 
saturated  solution  of  perchloride  of  mercury,  wash  well,  and  then  place  in  a 
strong  solution  of  ammonia. 

Printing 

The  printing  of  au  X-ray  negative  is  an  art  which  is  too  often  neglected 
by  the  radiographer.  A  well-finished  print,  nicely  glazed  and  suitably 
mounted,  is  the  finished  work  of  the  expert,  and  should  always  be  aimed  at, 
slovenliness  here  being  quite  inexcusable.  It  must  be  remembered  that  the 
average  plate  will  produce  a  print  which  will  explain  the  conditions  found, 
and  in  the  majority  of  cases  it  is  on  the  print  that  the  radiographer  is  judged. 
Consequently  it  should  always  be  the  aim  to  tuin  out  a  good  print.  The 
three  papers  commonly  used  in  printing  are  : 

(1)  Bromide  paper.  (2)  Gas-hght  paper.  (.3)  Silver  paper. 

Nos.  1  and  2  are  the  most  frequently  used  because  of  the  conveniences 
they  offer.  The  best  prints  are  undoubtedly  obtained  by  using  P.O. P.  paper, 
the  difficulty  being,  however,  that  a  strong  fight  is  required,  and  the  operator 
is  dependent  in  the  majority  of  cases  on  daylight  conditions.  When  day- 
light is  not  available  these  papers  may  still  be  used  by  the  aid  of  an  arc 
lamp,  by  the  use  of  which  a  negative  may  be  printed  in  from  ten  to  fiiteen 
minutes. 

The  toning  and  fixing  of  papers  so  prepared  is  a  fittle  more  troublesome 
than  when  papers  (1)  and  (2)  are  employed,  which  possess  the  advantage  over 
silver  paper  that  they  give  the  operator  the  opportunity  of  producing  a  good 
print  by  careful  development,  as  by  careful  manipulation  prints  of  good 
diagnostic  value  can  be  obtained  from  very  indifferent  plates.  It  must  be 
insisted  upon  that  the  touching  in  of  detail  should  never  be  practised  in 
radiographic  work.  Though  largely  used  in  artistic  photography,  it  has  no 
field  here. 

In  hospitals  and  in  private  practice,  where  large  plates  are  used  and 
several  are  taken  of  the  same  subject,  reduced  prints  may  be  obtained  by  the 
use  of  a  reducing  lantern.  By  using  an  apparatus  of  this  kind  it  is  possible 
to  obtain  in  a  small  space  prints  of  the  largest  plates.  These  may  be  mounted 
in  series  on  a  large  mount,  and  despatched  to  the  physician  or  surgeon  in 
charge  of  the  patient.  These  reduced  positives  are  quite  sharp,  show  all 
the  detail  of  the  large  prints,  and  may  be  included  in  the  notes  of  a  case. 
Plates  when  dried  should  be  carefully  cleaned  and  particulars  attached  to 
them.  When  examined  and  reported  on,  they  should  be  filed  away  and 
indexed.  The  card  index  system  will  be  found  most  useful  for  this  purpose. 
Special  cards  may  be  printed  to  suit  individual  requirements. 


102 


RADIOGRAPHY 


Further  Points  in  Exposure  and  Development 

It  is  worthy  of  note  that  a  practical  knowledge  of  photography  is  very 
helpful  to  the  radiographer,  and  in  no  part  of  his  work  more  so  than  in  the 
development  of  his  plates.     Fortunately  for  the  majority  of  workers  whose 


An  exposure 
of 

12  sees. 


10 


An  exposure 
of 

28  sees. 


24 


20 


16 


12 


Fig.  87. 


-To    illustrate   the   latitude    of  exposure.     Each  of  the   twelve  exposures  gives  a  good 
negative.     These  exposures  were  made  with  a  moderately  soft  tube. 


knowledge  of  photography  is  slight,  considerable  latitude  in  the  exposure 
time  exists. 

First  Experiment. — In  the  course  of  a  number  of  experiments  performed 
for  the  purpose  of  ascertaining  this  point,  it  was  found  that  if  a  limb  of  even 
thickness  was  radiographed,  being  divided  into  areas  which  allowed  of  twelve 
exposures  of  different  duration,  commencing  with  2  seconds  and  ranging  up 
to  20  to  30  seconds,  useful  negatives  were  obtained  from  each  exposure. 


PRACTICAL  POINTS  IN  EXPOSURE  103 

The  development  was  necessarily  uniform,  as  all  the  exposures  were  on  the 
one  plate. 

Second  Experiment. — On  this  occasion  the  same  duration  of  exposure 
was  given  to  each  part,  and  it  was  found  that  useful  negatives  were  obtained 
by  varying  the  time  of  development. 

Third  Experiment. — This  experiment  was  carried  out  with  a  view  to 
ascertaining  the  influence  of  temperature  on  the  action  of  the  developing 
agent.  A  wide  range  of  variations  was  found  which  are  very  instructive. 
Using  the  same  exposure  for  two  plates  and  developing  them  side  by  side, 
one  solution  being  about  20  per  cent,  colder  than  the  other,  it  was  found  that 
at  a  temperature  of  60°  development  was  rapid,  detail  good,  and  density 


Exposure 
2  seconds. 


Fig.  88. — To  illustrate  the  latitude  of  exposure.     Exposure  with  a  hard  tube. 

correct.  If  the  temperature  was  below  45°  the  resulting  picture  showed 
detail,  but  httle  density,  indicating  that  the  hydrokinone  had  not  been  able 
to  use  its  influence. 

Fourth  Experiment. — On  this  occasion  variations  in  exposure  were  made, 
the  times  of  exposure  being  as  1  to  5.  The  plate  exposed  for  the  shorter 
time  was  developed  at  60°  and  the  other  at  a  low  temperature.  It  was 
found  that  the  first  plate  gave  the  better  result. 

These  experiments  indicate  that  by  giving  minimum  exposures  the  wear 
and  tear  on  apparatus  and  tubes  is  lessened,  and  the  fogging  of  plates  by 
secondary  radiations  avoided,  while  by  proper  manipulation  of  the  developing 
solution  better  pictures  are  obtained.     A  further  advantage  of  using  the 


104  KADIOGRAPHY 

developer  at  a  proper  temperature  is  that  we  lessen  the  risk  of  fogging  the 
plate  bv  prolonged  exposure  to  even  a  "  safe  ruby  "  light,  and  also  the  risk 
of  chemical  fog  from  prolonged  immersion.  These  points  have  been  elabor- 
ated with  the  intention  of  showing  the  advantage  of  working  under  proper 
conditions.  It  is  hoped  that  they  may  explain  many  failures  in  cases  where 
good  results  should  have  been  obtained. 

Instructions  for  glazing  Gelatino-Chloride  Prints 

When  the  print  has  been  prepared  it  is  necessary  to  glaze  and  mount  it 
on  a  cardboard.  Too  great  stress  cannot  be  put  upon  this  part  of  the  work. 
A  properly  glazed  and  mounted  print  is  the  final  effort  of  the  radiographer. 

Plate  Glass  should  be  thoroughly  cleaned  in  w^arm  water  and  soda  to 
remove  dirt  and  grease,  and  then  well  rinsed  in  plain  water  to  remove  soda. 
Polish  ofi:  carefully  with  spirits  of  wine,  and  soft  leather.  Sprinkle  a  httle 
powdered  French  chalk,  and  again  poHsh  off  lightly  with  soft  leather. 

Prints  should  be  previously  well  hardened  in  alum  or  formalin.  If 
alum  is  used,  the  solution  should  be  filtered  before  use,  and  the  print  well 
washed  after.     If  formalin  is  used,  a  short  washing  will  suffice. 

Place  the  print  direct  from  washing-water  on  to  the  glass,  one  corner 
first,  allowing  the  surface  to  roll  into  contact ;  the  action  of  the  water  will 
then  exclude  air  bells.  Or  the  print  may  be  placed  on  the  glass  entirely  under 
water.  Lay  the  glass  on  a  firm  flat  table,  cover  with  a  piece  of  clean,  smooth 
blotting-paper,  and  squeeze  lightly  with  a  rubber  roller.  Heavy  pressure 
should  not  be  used,  but  merely  sufficient  to  remove  the  surplus  water,  leaving 
the  print  in  actual  contact  with  the  glass. 

Backing. — Cut  a  piece  of  waterproof  backing  paper  a  little  smaller  than 
the  print.  Paste  with  stiff  brush  evenly  and  thinly,  and  squeeze  lightly 
into  contact  with  the  back  of  the  print  on  the  glass.  Leave  till  thoroughly 
dr^.  Then  insert  the  point  of  a  knife  under  the  edge  of  the  print,  when  it 
will  strip  off  with  an  enamelled  surface. 


STEREOSCOPIC   RADIOGRAPHY 

A  great  deal  of  importance  is  attached  to  stereoscopic  radiography, 
many  workers  going  so  far  as  to  state  that  a  quick  stereoscopic  radiograph 
possesses  as  much  value  as  a  Rontgen  cinematographic  result.  It  is  certainly 
most  useful  in  depicting  subjects  like  renal  calculi,  stomachs,  intestines,  and 
fractures,  especially  of  the  pelvis  and  femur  ;  but  opinion  is  very  divided  as 
to  its  value  in  locating  foreign  bodies,  many  workers  claiming  that  better 
results  are  obtained  by  the  comparison  of  two  different  radiographs  taken  at 
a  much  wider  angle.  When  observing  any  object  or  group  each  eye  sees 
quite  a  different  picture,  but  the  two  images  thus  seen  are  combined  into  one 
picture  by  the  brain,  which  has  the  property  of  perspective.  To  accurately 
radiograph  stereoscopically,  therefore,  it  is  necessary  that  the  points  of  view 
should  be  the  same  distance  apart  as  the  pupils  of  the  two  eyes,  but  in  radio- 
graphy it  has  been  found  that  to  produce  the  best  rehef  it  is  necessary  to 
exaggerate  the  stereoscopic  effect.  It  is  necessary,  therefore,  to  take  two 
successive  radiographs  on  two  different  plates,  which  are  placed  in  exactly 
the  same  position,  to  keep  the  patient  absolutely  stationary,  and  to  shift  the 
tube  a  few  centimetres  to  either  side  of  the  centre.  The  correct  degree  of 
movement  for  the  tube  has  been  calculated  by  Marie  and  Ribaut,  who  have 
given  the  following  table,  but  this  need  not  be  absolutely  followed  if  the 
movement  of  the  tube  is  recorded. 

Marie  and  Ribaut's  Table 


Thickness  of  part 

Distance  of  the  Anti-cathode  to  the  surface  of  the  Body.                   | 

to  be  radio- 
graphed. 

1 

20  cm. 

30  cm. 

40  cm. 

50  cm. 

cm. 

cm. 

cm. 

cm. 

cm. 

2 

4-4 

9-6 

16-2 

^ 

4 

2-4 

5-4 

8-8 

13-5 

6 

1-7 

3-6 

6-1 

9-3 

8 

1-4 

2-8 

4-1 

7-3 

Distance    to    which 

10 

1-2 

2-4 

4-0 

6-0 

j-     the  tube  must  be 

15 

1-8 

2-9 

4-3 

displaced. 

20 

1-5 

2-4 

3-5 

25 

1-3 

2-1 

3-0 

30 

1-2 

1-9 

2-7        J 

The  point  to  bear  in  mind  is  that  the  nearer  the  object  of  interest  to  the 
plate  the  greater  the  distance  the  tube  must  be  moved  between  the  first  and 
second  exposure.     After  the  exposure  and  subsequent  development  the  two 

105 


106  RADIOGRAPHY 

images  must  be  optically  fused  into  one,  and  for  this  purpose  there  are 
many  forms  of  stereoscopes,  such  as  the  Wheatstone  reflecting,  prism  stereo- 
scope, and  the  Pirie  hand  stereoscope.  Both  pictures  can  be  reduced  and 
viewed  in  a  hand  stereoscope. 

As  to  the  necessary  apparatus  for  taking  stereoscopic  radiographs, 
if  only  those  parts  of  the  body  which  can  be  kept  stationary  without 
effort  are  required,  and  time  is  not  an  important  factor,  then  an  ordinary 
stereoscopic  plate-holder  can  be  used  where  the  patient  lies  upon  a  holder 
with  a  top  which  is  transparent  to  the  X-rays.  Into  this  holder  place  two 
plate-holders,  which  can  be  exchanged  without  moving  the  patient.  On  the 
other  hand,  if  stereoscopic  results  of  those  parts  of  the  body  which  cannot 
be  controlled  voluntarily  are  required,  then  an  automatic  arrangement 
must  be  adopted  to  shift  the  tube  and  the  plate  synchronously  and  in- 
stantaneously (see  Fig.  70).  There  are  already  several  of  these  devices  on 
the  market,  but  they  are  daily  being  improved,  and  we  shall  no  doubt 
shortly  have  a  perfect  one  produced. 

Stereoscopic  fluoroscopy  has  also  been  attempted,  but  although  possible 
and  indeed  successful  with  parts  of  the  body  such  as  the  hand  and  the  foot, 
this  has  hardly  been  satisfactory  with  the  thicker  parts. 


THE   LOCALISATION   OF   FOREIGN   BODIES 

The  demonstration  of  a  foreign  object  in  any  part  of  the  body  is  one  of 
the  most  useful  functions  of  the  X-ray  examination,  and  its  accurate  localisa- 
tion is  one  of  the  most  difficult  duties  of  the  radiographer.  Even  after  a 
body  has  been  definitely  localised,  the  surgeon  may  not  be  able  to  measure 
exactly  the  distances  from  given  points  so  as  to  make  his  incisions  and  extract 
the  foreign  body  at  once.  There  are  fallacies  in  the  interpretation  and  mis- 
calculations of  distance,  and,  lastly,  it  must  not  be  forgotten  that  if  a  foreign 
body  is  located,  the  patient  must  be  placed  in  exactly  the  same  position  at  the 
time  of  operation  as  he  occupied  when  the  radiographs  were  taken.  A  slight 
degree  of  flexion  or  rotation  of  a  limb  will  upset  the  calculations,  and  the 
foreign  body  may  be  found  to  be  as  much  as  1  or  2  inches  away  from  the  spot 
at  which  it  had  been  localised.  It  must  also  be  pointed  out  that  if  a 
locahsation  is  to  be  of  its  greatest  value  it  should  be  done  immediately 
before  the  surgeon  operates  ;  if  possible  it  should  be  done  in  the  operating 
theatre.  Where  many  cases  require  investigation  a  small  theatre  should 
be  attached  to  the  X-ray  department.  Of  the  various  methods  for  locahsing 
foreign  bodies  the  most  useful  and  probably  the  best  known  is  that  intro- 
duced by  Mackenzie  Davidson.  The  details  of  the  method  will  be  dealt 
with  later.  Modifications  of  this  method  exist,  and  have  been  used  by 
many  workers.  Foreign  bodies  are  met  with  in  all  parts  of  the  body,  and 
the  localisation  will  vary  in  difficulty  according  to  the  part  in  which  a 
foreign  body  is  found.  In  the  limbs  they  are  comparatively  easy  of  localisa- 
tion, but  in  the  skull,  thorax,  and  abdomen  the  greatest  difficulty  may  be 
experienced. 

Probably  the  best  all-round  method  of  localisation  in  the  latter  regions 
is  the  stereoscopic.  This  is  carried  out  in  the  same  way  as  in  ordinary 
stereoscopic  work.  Two  plates  are  necessary,  and  in  most  cases  it  will  be 
found  useful  to  place  on  the  skin  of  the  patient  an  opaque  body  which  will 
give  a  shadow,  and  may  be  used  as  a  landmark  for  subsequent  comparison. 
By  employing  cross  wires  the  stereoscopic  may  be  used  in  conjunction  with 
Mackenzie  Davidson's  method.  Stereoscopic  plates  should  be  developed 
together  in  order  to  secure,  if  possible,  the  same  density  of  negative  ;  simi- 
larly the  condition  of  the  tube  and  length  of  exposure  should  be  the  same 
for  each  plate.  A  note  should  be  made  of  the  position  of  the  plate  in  relation 
to  the  body  of  the  patient.     This  will  be  found  useful  when  it  is  necessary  to 

107 


108 


EADIOGEAPHY 


state  the  exact  position  of  the  foreign  body  in  relation  to  fixed  anatomical 
landmarks. 

Good  stereoscopic  negatives,  when  viewed  in  the  stereoscope,   show 
perfect  pictures,  with  the  correct  perspective  for  the  parts  shown,  though 


Fig.  89. — Wheatstone  stereoscope.     (Watson.) 

the  exact  localisation  of  a  foreign  body  may  be  difficult  or  in  some  instances 
impossible.  A  Wheatstone  stereoscope  should  be  employed  whenever 
possible,  as  it  affords  valuable  aid  by  means  of  its  adjustable  parts  in  quickly 
getting  the  correct  position  of  the  plates.  When  this  comparatively  elaborate 
stereoscope  is  not  available,  a  Pirie  hand  stereoscope  will  be  found  useful. 
Pirie  Stereoscope  for  the  Examination  of  X-Ray  Negatives. 
— The  Pirie  stereoscope  is  arranged  on  entirely  different  lines  from  the 
instruments  which  have  been  heretofore  employed  for  the  examination  of 

stereoscopic  X-ray  negatives. 
Instead  of  using  reflecting 
mirrors,  a  double  reflecting 
prism  is  used.  For  conveni- 
ence the  prism  is  mounted  in 
one  of  two  metal  tubes,  which 
are  bound  together  by  a  con- 
necting piece,  the  second  tube 
being  a  plain  one  only,  and 
serving  to  exclude  extraneous 
objects  from  view.  The 
stereoscope  is  light,  the  metal 
part  being  constructed  of  aluminium,  and  can  be  easily  carried  in  the  pocket. 
A  feature  of  the  Pirie  stereoscope  is  the  ease  with  which  stereoscopic  vision 
is  obtained.  It  frequently  happens  that  persons  who  are  not  accustomed 
to  examimng  stereoscopic  negatives  wish  to  do  so,  and  with  the  old  form  of 
reflecting  mirror  stereoscope  this  has  always  been  a  difficult  matter,  very 
often  ending  in  failure.  With  the  Pirie  stereoscope,  however,  it  is  almost 
impossible  for  anyone  to  avoid  seeing  the  negatives  stereoscopically.  The 
negatives  are  taken  in  the  usual  manner  and  are  placed  side  by  side,  either 


Fig.  90. — Pirie  stereoscope. 


SIMPLE  METHODS  OF  LOCALISATION  ]09 

in  suitable  boxes  provided  wtK  electric  light,  or  they  can  be  rested  on  the 
framework  of  a  convenient  window. 

The  distance  at  which  the  negatives  are  observed  depends  upon  the 
distance  between  the  centres  of  the  negatives,  that  is  to  say,  the  size  of  the 
plates.  For  instance,  the  best  position  to  inspect  a  pair  of  12  inch  by  10  inch 
negatives  placed  as  closely  together  as  possible  is  about  3  feet  6  inches. 
When  looking  at  smaller  negatives  it  is  necessary  to  come  much  closer  in 
order  to  obtain  a  comfortable  stereoscopic  effect,  or  with  larger  negatives 
the  distance  must  be  increased. 

The  negatives  should  be  on  a  level  with  the  eyes  and  if  possible  slightly 
tilted  towards  each  other. 

By  concentrating  the  attention  through  the  plain  tube  {i.e.  the  one  with- 
out the  prism)  and  centering  the  image  on  the  corresponding  side,  a  stereo- 
scopic effect  is  at  once  perceived  even  by  those  who  are  unaccustomed  to 
stereoscopic  work. 

The  correct  position  of  the  foreign  body  may  be  located  and  a  statement 
made  as  to  its  relative  position  to  well-known  landmarks,  but  when  operation 
for  removal  is  contemplated  the  surgeon  should  examine  the  plates  on  the 
stereoscope  and  form  a  mental  picture  of  the  position  of  the  foreign  body 
which  should  guide  him  throughout  the  operation.  To  facilitate  this  a 
stereoscope  should  be  placed  in  close  proximity  to  the  operating  theatre. 

Simple  Methods  of  Localisation. — There  are  simpler  methods  for 
localisation  which  may  be  employed  in  cases  which  are  not  likely  to 
require  an  exact  degree  of  measurement.  Foreign  bodies  in  the  limbs 
come  under  this  heading.  It  is  obvious  that  in  some  instances  one 
negative  is  sufficient  to  indicate  the  position  of  the  foreign  body,  though 
it  is  surprising  how  difficult  an  apparently  easy  case  may  become  under 
some  circumstances.  All  operations  for  removal  should  be  undertaken 
as  soon  as  possible  after  the  radiograph.  More  difficult  cases  require  more 
elaboration,  and  in  all  instances  of  bodies  in  the  limbs  two  radiographs  should 
be  taken  :  (1)  antero-posterior  position,  (2)  lateral  position.  The  limb  need 
not  be  moved  when  these  exposures  are  made.  A  simple  plate-holder  with 
a  second  one  at  right  angles  will  suffice.  The  tube  alone  requires  to  be  moved. 
An  examination  of  the  two  negatives  should  give  the  position  of  the  foreign 
body.  In  the  plate  taken  in  position  (1),  the  distance  from  a  given  point, 
probably  a  bony  landmark,  is  taken.  The  plate  taken  in  position  (2)  shows 
the  depth  from  the  surface.  In  most  instances  this  should  be  sufiicient,  as 
the  operator  has  only  to  measure  the  distances  and  make  a  mental  note  of 
the  position. 

In  order  to  get  a  graphic  record  of  the  measurements,  a  simple  plate- 
holder  can  be  constructed  with  an  inch  or  centimetre  rule,  which  slides  over 
the  surface  of  the  plate  so  that  it  may  be  placed  in  relation  to  a  bone  or  foreign 
body.  A  second  inch  or  centimetre  scale  runs  at  right  angles  to  the  longi- 
tudinal one.  The  marks  on  the  scale  are  rendered  opaque  by  inserting 
pieces  of  wire  into  the  wood  at  the  correct  distances.  The  second  plate-holder 
is  fixed  at  right  angles  to  the  first  one  and  also  has  sliding  scales.     The 


110 


EADIOGEAPHY 


foreign  body  may  be  located  by  screening  prior  to  the  taking  of  the  plates. 
When  the  two  negatives  are  examined  it  is  easy  to  locate  accurately  the 

G 


*o»fe 


Fig.  91. — Diagram  to  show  method  of  taking  a  lateral  view. 

A,  Source  of  X-rays.  H,  Shadow  of  foreign  body  on  plate. 
D,  Foreign  body.  F,  Shadow  of  bones. 

0,  Bones.  G,  Graduated  scale. 

B,  Limb. 


foreign  body.  The  plates  have  on  the  surface  an  exact  rule  for  measuring. 
For  exact  localisation  the  Mackenzie  Davidson  method  should  be  employed. 
Method  employed  in  Mackenzie  Davidson  Localisation. — The 
central  ray  emitted  from  an  X-ray  tube  has  to  be  definitely  found.  To  do 
this  it  is  necessary  to  have  an  arrangement  for  determining  the  central  ray. 
The  tube  is  accurately  fixed  on  the  box  beneath  the  table  ;  the  latter  moves 
in  two  directions  on  trolley  wheels.  The  central  ray  is  located  by  means  of 
cross  wires,  or  a  plumb-line  rmming  on  pulleys  and  moving  with  the  tube, 
so  that  whatever  the  position  of  the  tube  the  plumb-line  always  indicates  the 
position  of  the  focus  of  rays  upon  the  anti-cathode.  The  distance  of  the 
anode  from  the  top  of  the  couch  is  constant,  and  should  be  recorded  on  a 
convenient  place  on  the  couch ;  the  distance  of  the  plate  from  the  top  of  the 
couch  must  also  be  taken  into  consideration.  The  two  added  together  give 
the  distance  of  the  anode  from  the  plate.  When  working  with  the  tube  above 
the  patient,  the  two  positions  of  the  anode  are  secured  by  moving  the  tube 
along  a  horizontal  bar  which  is  marked  with  a  milhmetre  scale,  running  both 
ways  from  a  central  point  at  zero.  The  sensitive  plate  or  film  is  placed  under- 
neath, and  protected  in  the  usual  way  by  black  paper,  or  it  may  be  placed  in 
a  light-tight  casette.  Two  wires  are  laid  at  right  angles  to  each  other  on  the 
photographic  envelope,  and  so  placed  that  one  of  them  runs  in  the  same 
direction  as  the  horizontal  bar  which  carries  the  tube  above,  and  their  point 
of  intersection  Hes  beneath  zero  on  the  scale.     The  cross  wires  may  be 


MACKENZIE  DAVIDSON  METHOD 


111 


fastened  to  a  thin  board  or  sheet  of  vulcanite,  and  retained  in  position  over 
the  sensitive  plate  by  drawing-pins,  or  they  may  be  permanently  fixed  to  a 
frame,  upon  which  the  plate  is  placed.  The  marks  corresponding  to  the  cross 
wires  should  be  painted  with  aniline  ink  or  silver  nitrate  solution,  so  as  to  leave 
a  mark  on  the  body  of  the  patient,  and  it  is  convenient  to  identify  one  of  the 
corners  of  the  plate  by  some  opaque  object,  such  as  a  small  coin,  with  a 
corresponding  sign  on  the  adjacent  skin  surface.  Two  equidistant  points 
are  marked  of?  by  clips,  or  any  other  method,  at  each  side  of  zero  on  the 
horizontal  scale  bar,  at  a  distance  decided  on  by  the  operator.  The  focus- 
tube  is  drawn  up  to  one  side-clip,  and  an  exposure  made.     It  is  then  pushed 


A 

-0 


over  to  the  other  clip,  and 
a  second  exposure  made 
of  equal  length.  The  dis- 
tance from  the  centre  point 
of  the  anode  to  the  plate 
is  then  accurately  mea- 
sured. Accurate  data  have 
now  been  obtained,  from 
which  the  operator  may 
calculate  the  exact  relation 
of  a  foreign  body  in  the 
tissues  to  the  aniline  cross 
mark  on  the  patient's  skin. 

When  the  tube  is 
operated  from  below  a 
similar  arrangement  is 
used,  the  tube  being  first 
centred  over  a  known  point 
of  the  part  to  be  radio- 
graphed. A  scale  is  at- 
tached to  a  convenient  part 
of  the  table  and  the  move- 
ment to  one  side  (a  known 
distance)  is  made,  say  3  cm. 
The  tube-box  is  fixed  and  the  exposure  is  then  made.  The  plate  is  removed 
and  a  second  one  placed  in  exactly  the  same  position.  The  tube  is  now 
moved  6  cm.  in  the  opposite  direction  to  the  first  movement,  and  the  second 
exposure  is  made.  It  should  be  noted  that  the  frame  with  the  cross  wires 
and  the  plates  occupies  the  same  position  relative  to  the  patient  during  the 
two  exposures.  It  is  also  possible  to  make  the  two  exposures  on  one  plate 
by  exposing  only  half  at  a  time,  thus  enabhng  a  little  time  to  be  saved  in  the 
subsequent  procedures  for  locahsation. 

Having  obtained  the  radiographic  records  the  next  step  is  to  proceed  to 
the  exact  locahsation  of  the  foreign  body.  This  is  done  by  means  of  the 
cross-thread  localiser  (Mackenzie  Davidson).  The  apparatus  consists  of  an 
adjustable  horizontal  bar,  which  is  marked  with  a  millimetre  scale  starting 


Fig.    92.- 


D  C 

-Diagram    showing    Mackenzie    Davidson    method. 
(After  Walsh.) 

.1,  First  position  of  tube.  D,  Shadow  thrown  on  plate  by 

B,  Second  position  of  tube.  tube  in  A  position. 

S,  Skull  or  limb.  C,  shadow  thrown  on  plate  by 

F  B,  Foreign  body.  tube  in  B  position. 

Dotted  lines  represent  the  paths  of  the  rays. 


112 


KADIOGRAPHY 


from  a  central  zero,  and  is  notched  to  correspond  on  its  upper  edge ;  a 
plate-glass  stage  marked  with  two  lines  at  right  angles  to  each  other,  the  point 
of  intersection  lying  exactly  beneath  zero  on  the  horizontal  bar.  Beneath 
the  stage  is  a  hinged  reflecting  mirror.  The  developed  negative  or  tracings 
of  the  two  plates  on  a  celluloid  sheet  is  placed  film  upwards  on  the  glass 
stage,  and  the  shadow  of  the  wires  made  to  correspond  with  the  cross  mark 
on  the  stage.  The  bar  is  next  raised  or  lowered  so  as  to  bring  the  zero  of  the 
scale  to  the  same  distance  from  the  scale  as  that  of  the  centre  of  the  anode 
from  the  sensitive  plate  when  the  exposures  were  made.  Two  fine  silk  threads 
are  next  passed  over  the  horizontal  scale  bar.  Each  thread  has  a  weight  at 
one  end  to  keep  it  taut,  and  is  fixed  in  a  notch  on  the  scale  corresponding 

with  the  distance  of  the 
anode  from  zero  during 
the  original  exposure. 
The  other  end  is 
threaded  into  a  fine 
needle  fixed  in  a  piece 
of  lead.  The  path  of 
the  thread  between  the 
notch  on  the  scale  and 
the  eye  of  the  needle 
represents  the  path  of 
the  X-ray  and  is  mov- 
able. A  second  thread 
is  passed  through  the 
notch  at  the  other  end 
of  the  horizontal  bar. 
It  represents  the  path 
of  the  rays  during  the 
second  exposure  after 
the  tube  has  been 
moved. 

With  two  such 
threads,  then,  it  will  be 
easy  to  trace  the  path  of 
the  rays  in  relation  to  a  body  interposed  between  the  focus-tube  and  the 
sensitive  plate.  One  threaded  needle  is  placed  upon  any  particular  part  of 
one  of  the  photographic  shadows  of  the  foreign  body,  and  the  other  needle 
upon  a  corresponding  part  in  the  second  shadow.  The  point  where  the 
threads  cross  and  touch  each  other  will  represent  the  position  of  the  part  of 
the  foreign  body  chosen  for  location.  A  perpendicular  is  then  dropped 
from  the  intersection  of  the  threads  to  the  negative  below,  and  a  mark 
made  where  the  perpendicular  touches  the  negative.  The  distance  of  the 
spot  thus  marked  out  from  the  cross  wires  is  measured  by  a  pair  of  com- 
passes. The  operator  is  now  in  possession  of  the  required  measurements. 
If  the  distances  are  3  cm.  and  1  cm.,  and  the  depth  from  the  crossing  of 


Fig.  93. — Mackenzie  Davidson  cross-thread  localiser.    (Cox  and  Co.). 


MODIFICATIONS  OF  MACKENZIE  DAVIDSON  METHOD    113 


the  threads  to  the  plate  2|  cm,,  then  he  knows  that  the  foreign  body 

lies  at  2|  cm.  from  the  surface  of 

the  patient's  skin,  at  a  distance  of 

3  cm.  and  1  cm.  from  the  cross 

wires,  in  a  quadrant  that  is  easily 

determined   by    reference    to    the 

distinguishing   mark  placed  there 

when  taking  the  double-exposure 

radiograph. 

Dawson,  Turner,  and  others 
have  published  a  simple  formula 
for  localising.  Two  radiographs 
are  taken  on  one  plate  by  moving 
the  tube  a  known  distance.  The 
distances  are  measured  from  tube 
to  plate  (A),  between  the  two  posi- 
tions of  the  tube  (B),  and  between 
the  two  shadows  on  the  photo- 
graphic plate  (C).     Let  x  equal  the 


Fig.  94.- 


-Diagrani  to  illustrate  simple  formula  for 
localising.     (After  Walsh. ) 


distance  of  the  foreign  body  from  the  plate. 
Then 

X 


axe 
h+c 


Supposing  a  to  be  33  cm.,  6  10  cm.,  and  c  1  cm.,  then 
33x1 


x  = 


=  3  cm. 


10  +  1 
Mackenzie  Davidson  has  suggested  a  short  method 
of  locaUsation  which,  while  based  on  his  original 
method,  allows  of  more  rapid  locaUsation.  The 
central  ray  is  determined  and  the  position  fixed 
by  means  of  a  plumb  line.  The  foreign  body  is 
located  directly  under  the  point  of  the  plumb  hne. 
A  mark  is  made  upon  the  skin,  a  plate  is  exposed, 
the  tube  is  moved  a  known  distance,  and  a  second 
exposure  made.  The  depth  of  the  body  is  deter- 
mined by  calculation  in  the  ordinary  way.  Two 
cross  wires,  arranged  at  right  angles,  must  be  used. 
Dr.  Hampson  has  simplified  this  method  still  further 
by  having  a  graduated  scale  fixed  to  the  fluorescent 
screen.  By  movement  at  the  time  of  screening  he  is 
able  to  say  the  depth  of  the  foreign  body  at  a  point 
vertically  below  the  skin  mark.  This  method  can 
only  be  used  at  a  fixed  distance  in  all  cases  unless 
separate  scales  are  worked  out  for  each  position  of 
the  tube  in  relation  to  the  screen  or  plate.  The 
method  is  more  fully  described  on  p.  114. 

8 


Fig.  95.'— To  illustrate  Mac- 
kenzie Davidson's  short 
method  of  localisation. 

4  :  X  : :  10  :  50  -  a-. 

F  B,  Foreign  body. 

A,  First  position  of  tube. 

B,  Second  position  of  tube. 

C,  Position  of  image  of  F B  in 

first  position.  A  mark 
is  made  on  the  skin  at 
this  spot. 

D,  Shadow  of  T^iJ  in  second 

position  of  tube. 


114 


RADIOGEAPHY 


l^itrT'i"fTi'V;i^T'VTi'k"r''r"'Y"'1r"'^'' 


cm. Depth:  RB. 

Fig.  96. — Graduated  scale  in  Hampfsoii  localiser. 


Hampson's  Method  of  Localisation.— The  method  introduced  by 
Dr.  Hampson  is  briefly  as  follows  : 

Place  the  patient  on  the  couch  and  arrange  the  tube  in  the  tube-box 

with  the  focus  point  at  a  determinate  distance,  say  50  cm., beneath  the  surface 

n  of  the  screen.     Contract  the 

fm  on  \crppn 

'  '■  *^"  ^^i^^it-  diaphragm  openmg  so  as  to 

make  it  easy  to  centre  the 
foreign  body  in  the  field  of 
view.  The  rays  through  it 
will  be  practically  vertical, 
and  a  small  arrow  head  or 
other  metallic  mark  fixed 
on  the  skin  will  locahse  the 
selected  point  of  the  foreign 
body  in  two  dimensions, 
along  and  across  the  trunk  or  limb.  For  the  estimation  of  the  depth  a  mark 
is  placed  on  the  glass  of  the  screen  over  a  selected  point  of  the  foreign  body. 
Move  the  tube-box,  and  with  it  the  focus,  a  known  distance,  say  10  cm., 
and  mark  on  the  glass  the  new  situation  of  the  selected  point,  opening  the 
diaphragm  wider  if  necessary.  Measure  the  distance  that  the  shadow  of 
the  point  has  travelled,  read  this  off  on  the  upper  side  of  the  scale.  Fig.  96, 
and  the  corresponding  number  on  the  lower  scale 
will  be  the  depth  of  the  foreign  body  beneath  the 
screen.  If  the  part  of  the  patient  under  examination 
is  concave  and  does  not  touch  the  screen,  this  must 
be  allowed  for  in  stating  the  depth. 

In  cases  where  the  distance  between  the  screen 
and  focus  point  cannot  be  permanently  adjusted,  the 
same  result  can  be  obtained  with  very  little  trouble 
and  delay.  Ascertain  by  measurement  what  the 
distance  is,  mark  the  traverse  of  the  shadow  as 
before,  and  then  work  out  the  result  as  follows  : 

AB,  Fig.  96a,  is  a  line  equal  to  the  vertical 
height  from  screen  to  focus. 

AC  is  the  horizontal  movement  of  the  focus. 
BD  is  the  horizontal  movement  of  the  shadow 
on  the  screen. 

Draw  a  line  DC  intersecting  AB  in  E. 
Then  BE  is  the  depth  of  the  foreign  body  below 
the  screen. 

The  correctness  of  the  result  depends  on  the 
accuracy  of  the  measurements,  so  these  should  be 

made  as  few  as  possible  in  order  to  reduce  the  occasions  for  inaccuracy. 
It  is,  therefore,  better  to  measure  directly  the  distance  from  focus  level 
to  screen  by  means  of  a  large  pair  of  callipers. 

Other  distances  than  50  cm.  may  be  used,  but  a  separate  scale  must 


Fig.  96a.- — Hampson  local- 
iser. Diagram  to  illus- 
trate method. 


FOREIGN  BODIES  IN  SPECIAL  LOCALITIES  115 

be  prepared  for  each  distance.     A  table  prepared  for  the  50  cm.  interval  will 
be  found  useful  : 

-h  cm.  ti'averse  on  screen  means  a  depth  of    2J  cm. 

i  „  „  „  H      :, 

2  „  „  „  8^    „ 

3  „  „  „  Hi  „ 

4  „  „  „  14^    „ 

Shenton's  Method  of  Localisation. — Shenton  relies  entirely  on  the 
screen  method  of  examination  and  denounces  all  radiographic  methods. 
He  uses  a  circular  diaphragm  of  small  diameter  and  centres  this  accurately 
under  the  foreign  body.  A  metallic  pointer  or  probe  is  now  passed  between 
the  screen  and  the  limb  under  investigation,  and  its  tip  placed  over  the 
shadow  of  the  foreign  body,  or  to  be  more  correct,  the  shadow  of  the  probe 
is  watched  until  it  coincides  with  the  shadow  of  the  bullet,  the  probe  is  held 
steadily  in  position,  the  room  is  lighted  up,  and  the  exact  position  of  the 
probe  point  is  marked  upon  the  skin  surface.  This  is  a  point  immediately 
over  the  bullet,  and  it  is  manifest  that  an  incision  carried  to  a  correct  depth 
must  find  the  object  sought  for.  It  remains  therefore  to  ascertain  the  exact 
depth  at  which  this  lies.  A  straight  probe  is  used.  Around  it  is  twisted 
a  piece  of  lead  foil  or  soft  wire  so  as  to  make  an  appreciable  bulge.  Turn 
the  limb  upon  its  side,  i.e.  at  right  angles  to  its  former  position  ;  then  place 
the  tip  of  the  prepared  probe  on  the  spot  marked  upon  the  skin,  letting  the 
probe  lie  horizontal  to  it,  or  in  other  words,  parallel  with  the  screen.  Next 
slide  the  piece  of  lead  foil  along  the  probe  until  its  distance  is  equal  to  that 
of  the  point  from  the  bullet  or  other  foreign  body.  The  distance  between 
the  point  of  the  probe  in  contact  with  the  skin  and  the  bulge  caused  by  the 
lead  foil  is  equal  to  the  distance  between  the  skin  surface  and  the  position 
of  the  bullet.  The  distance  may  be  measured  upon  the  probe,  and  the 
operator  is  in  a  position  to  say  that  the  bullet  lies  under  the  spot  already 
marked  upon  the  skin,  and  that  the  depth  corresponds  to  a  known 
distance  as  measured  by  the  probe  and  the  movable  bulge  upon  it. 

Shenton  has  introduced  a  localiser  which  he  says  is  really  a  depth-gauge. 
This  is  a  very  ingenious  and  useful  apparatus  for  locahsing  foreign  bodies 
in  the  limbs. 


Localisation  of  Foreign  Bodies  in  Special  Localities 

Localisation  of   Foreign  Bodies  in   the  Eye  and  Orbit. — (a) 

Mackenzie  Davidson  method.  This  is  a  method  for  exact  localisation 
of  a  foreign  body  in  the  eyeball,  A  special  adjustable  head-piece,  fixed 
to  a  chair,  is  employed.  It  usually  consists  of  a  horizontal  arm,  carrying 
an  open  rectangular  framework,  across  which  two  wires,  one  vertical  and  the 
other  horizontal,  are  stretched,  and  against  which  the  photographic  plate  is 
placed.  Attached  to  the  framework  is  a  small  rifle  "  sight,"  at  the  same 
level  as  the  intersection  of  the  cross  wires,  the  use  of  which  will  be  presently 


116  KADIOGRAPHY 

described,  while  below  and  to  one  side  is  a  chin-rest,  so  that  the  patient  does 
not  move  his  head  while  the  plates  are  changed  and  the  exposures  made. 
Parallel  to  the  arm  carrying  the  open  framework  is  another  arm,  bearing  a 
sliding  clamp  for  the  X-ray  tube.  In  this  way  the  tube  always  moves 
parallel  to  the  horizontal  cross  wire.  The  tube  is  first  arranged  with  the 
glistening  point  of  origin  of  the  X-rays  on  the  anode  exactly  opposite  the 
intersection  of  the  cross  wire,  this  being  done  by  arranging  the  rifle  "  sight," 
the  point  of  intersection  of  the  wires,  and  the  point  on  the  anode,  all  in  the 
same  straight  line.  The  distance  between  the  point  on  the  anode  and  the 
intersection  of  the  wires,  usually  about  35  cm.,  is  carefully  measured.  The 
patient  now  sits  in  the  chair,  with  his  head  between  the  two  horizontal  arms, 
and  with  his  chin  placed  on  the  chin-rest,  places  the  side  of  his  head  (injured 
eye  side)  against  the  cross  wires,  so  that  they  are  between  his  head  and  the 
photographic  plate,  and  looks  straight  forward,  as  if  at  a  distant  object,  so 
that  the  visual  axis  of  his  eye  is  parallel  to  the  horizontal  cross  wire.  A  piece 
of  lead  wire,  exactly  1  cm.  long,  is  fixed  to  the  lower  eyelid  of  his  injured  eye 
by  adhesive  plaster,  and  the  distance  between  the  upper  end  of  the  wire 
and  the  centre  of  the  cornea  in  this  position  noted.  The  tube  is  now  moved 
3  cm.  to  one  side  of  its  original  position  and  an  exposure  made.  Another 
plate  is  put  in  position,  and  the  tube  slid  6  cm.  in  the  opposite  direction, 
and  another  exposure  made  without  the  patient  moving  his  head.  The  two 
plates  are  developed  and  fixed  in  the  usual  manner.  The  head-piece  is  usually 
made  with  the  cross  wire  framework  and  tube-holder  fitting  on  both  arms, 
so  that  either  eye  can  be  radiographed. 

The  shadows  of  the  foreign  body,  if  there  is  one,  on  the  negatives  have 
now  to  be  localised,  and  for  this  purpose  the  cross-thread  localiser  is  used. 
This  is  simply  an  apparatus  for  placing  the  negatives  in  exactly  the  same 
geometric  conditions  under  which  they  have  been  made,  and  it  has  been 
fully  described  on  page  112. 

With  these  means  we  can  now  reconstruct  the  exact  conditions  under 
which  the  two  skiagrams  were  taken.  The  horizontal  bar  is  arranged  so  as 
to  be  at  the  same  distance  from  the  plate-glass  as  the  point  on  the  anode  was 
from  the  cross  wires.  The  two  threads  passing  through  the  two  notches 
3  cm.  to  each  side  of  the  central  point  of  the  bar  will,  therefore,  represent 
the  paths  of  the  X-rays  when  the  exposures  were  made. 

A  thin  piece  of  varnished  celluloid,  also  having  cross  lines  scratched  on 
it,  is  placed  against  the  film  side  of  the  negative,  so  that  the  cross  lines  corre- 
spond in  both,  and  the  position  of  the  foreign  body  is  marked  by  pen  or  pencil 
on  the  varnished  celluloid,  as  well  as  the  shadow  of  the  lead  wire  on  the  lower 
eyelid.  The  same  is  done  with  the  other  negative  using  the  same  piece  of 
celluloid.  In  this  way  we  get  two  shadows  of  the  foreign  body  and  of  the  lead 
wire  in  their  relation  to  one  outline  of  the  cross  wires.  The  celluloid  with 
these  markings  is  now  placed  on  the  plate-glass,  with  the  cross  lines  corre- 
sponding in  both.  The  ends  of  the  cross  threads  attached  to  the  weighted 
needles  are  placed  on  the  markings  of  the  foreign  body  in  such  a  way  that  the 
shadow  of  the  foreign  body  to  the  right  is  at  the  end  of  the  thread  passing 


FOREIGN  BODIES  IN  THE  EYE  AND  ORBIT  117 

through  the  notch  on  the  left,  and  vice  versa.  These  threads  representing 
the  paths  of  the  X-rays  in  the  two  exposures,  the  points  where  they  cross  will 
represent  the  point  in  space  of  the  foreign  body. 

To  localise  the  point  one  has  to  measure  the  perpendicular  distance  of 
the  intersection  of  the  threads  from  three  planes  at  right  angles  to  each  other. 
The  vertical  distance  of  the  point  of  intersection  from  the  celluloid  is  measured 
by  a  pair  of  compasses,  and  this  distance  represents  the  depth  of  the  foreign 
body  from  the  skin,  as  the  side  of  the  head  was  against  the  cross  wires.  Next, 
the  distances  between  the  two  vertical  planes  represented  by  each  of  the  cross 
lines,  and  the  point  of  intersection,  are  measured.  To  do  this  an  upright 
square  is  placed  with  its  edge  coincident  with  one  of  the  cross  lines,  and  the 
perpendicular  distance  is  measured  by  compasses.  The  same  is  also  done 
with  respect  to  the  plane  of  the  other  cross  line.  These  measurements 
determine  a  point  on  the  skin  at  the  side  of  the  head  directly  beneath  which 
the  foreign  body  lies,  provided  we  know  the  relation  of  the  cross  wires  to  the 
patient's  skin.  If  the  foreign  body  is  of  any  size  it  is  necessary  to  determine 
the  exact  location  of  each  end  of  its  shadow,  but  if  it  is  very  small  one  measure- 
ment is  sufficient. 

As  the  location  of  a  foreign  body  as  being  at  such  and  such  a  depth  from 
the  skin  of  the  temple  would  not  give  the  surgeon  much  practical  help,  one 
must  be  able  to  state  its  relation  to  the  part  of  the  eyeball.  It  was  for  this 
reason  that  the  lead  wire  was  placed  on  the  lower  eyelid.  The  location  of 
the  upper  end  of  the  lead  wire  is  determined  in  relation  to  the  three  planes 
exactly  as  the  foreign  body  was,  and  after  this  it  is  merely  a  matter  of  addi- 
tion or  subtraction  to  be  able  to  tell  how  many  centimetres  the  foreign  body 
lies  behind,  at  a  higher  or  a  lower  level  than,  and  to  which  side  of,  the  upper 
end  of  the  wire.  We  already  know  the  distance  between  the  upper  end  of 
the  lead  wire  and  the  centre  of  the  screen,  and  as  the  wire  is  usually  at  the 
same  level  as  a  vertical  line  from  the  front  of  the  screen,  we  can  give  the 
surgeon  a  definite  point  at  which  the  foreign  body  is  lying  in  relation  to  the 
centre  of  the  cornea,  so  many  centimetres  behind  parallel  to  the  visual  axis, 
so  many  horizontally  to  the  nasal  or  temporal  side,  and  so  many  above  or 
below  it.  For  example,  suppose  we  have  found  the  position  of  the  inter- 
section of  the  cross  threads  marking  the  foreign  body  (6)  to  be  1-9  cm.  above 
the  celluloid,  3  cm.  behind  the  plane  of  the  vertical  cross  line  (B),  and  1  cm. 
below  the  plane  of  the  horizontal  cross  line  (A),  and  the  intersection  of  the 
thread  working  the  upper  end  of  the  lead  wire  {a)  to  be  2-9  cm.  above  the 
celluloid,  1-2  cm.  behind  the  plane  of  the  vertical  line  (B),  and  -6  cm.  below 
the  plane  of  the  horizontal  line  (A),  then  by  subtraction  the  foreign  body  is 
1  cm.  to  the  temporal  side,  1-8  cm.  behind  and  -4  cm.  below  the  upper  end 
of  the  lead  wire,  and  as  the  latter  is  -5  cm.  below  the  centre  of  the  cornea,  we 
are  able  to  say  that  the  foreign  body  lies  1-8  cm.  behind,  1  cm.  to  the 
temporal  side,  and  -9  cm.  below  the  centre  of  the  cornea,  with  the  eye  looking 
at  a  distant  object. 

Lastly,  it  should  be  remembered  that  the  skiagrams  taken  in  this  way 
are  stereoscopic,  and  if  so  viewed  will  give  a  stereoscopic  effect ;  and  as 


118  KADIOGRAPHY 

the  lead  wire  is  of  the  known  length  of  1  cm.,  it  maybe  used  stereoscopically 
as  to  scale  to  estimate  approximately  the  size  and  position  of  the  foreign  body. 

(6)  Sweet's  Method  of  Localisation. — Dr.  Sweet's  method  of  localising 
foreign  bodies  in  the  eye  and  orbit  is  carried  out  by  means  of  the  special 
apparatus  designed  by  him  for  the  purpose.  The  illustration  on  page  124 
shows  the  device,  which  comprises  a  head-rest  for  securing  the  head  of  the 
patient  above  a  plate-holder,  so  that  plates  can  be  changed  and  one-half 
exposed  without  disturbing  the  patient.  The  pneumatic  cushion  shown 
is  placed  between  the  patient's  head  and  the  plate-holder. 

In  use,  the  patient's  head  is  placed  in  position  and  the  indicator  shown  on 
the  right-hand  side  is  placed  in  exact  alignment  with  the  centre  of  the  cornea. 
The  indicator  is  then  pushed  gently  up  to  the  eye  itself,  and  when  just  touch- 
ing it  is  released  and  carried  back  by  a  spring  exactly  10  millimetres.  Two 
exposures  are  made,  the  first  with  the  anti-cathode  of  the  X-ray  tube  in  the 
same  plane  as  the  plate,  and  with  one-half  of  the  plate  covered.  The  un- 
exposed half  of  the  plate  is  then  brought  into  position,  and  a  second  exposure 
made  with  the  tube  slightly  tilted.  After  development  the  positions  of  the 
foreign  body  and  of  the  indicator  are  plotted  upon  a  special  chart  sheet,  a 
number  of  which  are  supplied  with  every  instrument.  It  should  be  noted 
that  it  is  not  necessary  to  place  the  tube  at  any  known  distance  from  the 
plate,  or  move  the  tube  an  exact  distance  for  the  second  exposure.  The 
special  charts  prepared  on  squared  paper  show  exactly  the  relative  position 
of  the  indicator  and  foreign  body. 

(c)  Stereoscopic  Method. — This  is  a  most  useful  method,  and  should 
always  be  employed,  even  when  an  exact  localisation  by  other  methods  has 
been  carried  out.  It  is  necessary  to  take  the  radiographs  in  two  positions  : 
(1)  Lateral,  and  (2)  antero-posterior.  When  these  radiographs  are  examined 
httle  doubt  should  exist  as  to  the  size  and  position  of  the  foreign  body, 
provided  the  operator  knows  the  position  of  the  plates  when  the  radiographs 
correspond. 

When  used  in  combination  with  Mackenzie  Davidson's  method  it  is 
the  most  accurate  of  all. 

(d)  Simpler  methods  may  be  employed.  Two  positions  are  necessary  : 
(1)  Lateral,  (2)  antero-posterior.  Two  pictures  of  the  foreign  body  are 
obtained  on  one  plate  by  maldng  the  first  exposure  with  the  eye  looking 
upwards,  the  second  with  the  eye  looking  downwards.  Movement  indicates 
the  position  of  the  body  in  relation  to  the  eyeball.  An  antero-posterior  plate 
should  also  help  to  locate  the  position  of  the  foreign  body.  This  method  is 
necessarily  inaccurate,  and  can  only  be  used  to  determine  the  presence  of  a 
foreign  body.  Should  operation  be  necessary,  then  an  exact  localisation 
by  the  Mackenzie  Davidson  method  must  be  carried  out.  In  regions  of  the 
body,  such  as  the  thorax  and  abdomen,  the  same  measures  may  be  employed. 
Stereoscopic  radiograms  of  the  thorax  in  the  antero-posterior  and  lateral  posi- 
tions should  sufiice  to  indicate  the  position  of  the  foreign  body.  The  cross- 
thread  method  of  localisation  should  be  employed  as  a  confirmatory  measure. 

Localisation    of  Foreig-n    Bodies    in  the  Skull.  —  The  methods 


SIMPLE  METHODS  OF  LOCALISATION  119 

available  are  (a)  stereoscopic  ;   (6)  stereoscopic  combined  with  Mackenzie 
Davidson  method. 

A  simple  method  may  be  employed  when  it  is  not  possible  to  have 
access  to  the  two  methods  referred  to.  It  is  one  which  anyone  possessing  an 
X-ray  installation  can  carry  out,  and  which  has  proved  useful  in  many 
instances.  Three  plates  are  required  :  (1)  Right  lateral,  (2)  left  lateral,  (3) 
antero-posterior.  For  the  localising  of  foreign  bodies  in  the  head  the  skull 
is  divided  into  sections  by  means  of  flexible  wire.  A  piece  of  wire  is  fixed  in 
the  longitudinal  diameter,  extending  from  the  nasion  in  front  to  the  external 
occipital  protuberance  behind.  A  second  wire  is  carried  from  the  nasion 
through  the  centre  of  the   external  auditory  meatus  backwards  to  end 


Fig.  97. — Bullet  in  brain.     Fragments  in  face. 

below  the  occipital  protuberance.  A  third  wire  is  carried  vertically  over 
the  skull  from  one  external  auditory  meatus  to  the  other.  Three  plates 
are  taken  and  compared.  When  the  foreign  body  is  sharper  on  one  plate 
than  on  the  others  it  indicates  that  it  is  nearer  to  the  side  on  which  it  is 
sharpest.  The  antero-posterior  plate  confirms  this  observation.  The  lateral 
pictures  also  serve  to  show  the  relationship  of  the  foreign  body  to  a  well- 
known  landmark  at  the  base  of  the  skull. 

Localisation  of  Foreig-n  Bodies  in  Regrion  of  Hip  and  Shoulder. 
— In  these  regions  it  is  impossible  to  get  more  than  one  position,  so  stereo- 
scopic radiographs  should  be  taken.  These  combined  with  the  Mackenzie 
Davidson  method  give  the  most  accurate  results. 

Localisation  of  Foreig-n  Bodies  in  the  Limbs. — In  a  number  of 
instances  it  may  be  possible  to  locate  the  foreign  body  by  screening  alone. 


120 


EADIOGRAPHY 


In  other  instances  one  of  the  methods  described  by  Mackenzie  Davidson, 
Hampson,  Shenton,  and  others  may  be  used.  The  position  of  the  foreign 
body  is  ascertained  and  a  mark  placed  on  the  skin  surface  immediately 


Fig.   98. — Fracture  of  lower  jaw  ;  foreign  body  in  soft  parts  ; 
a  portion  of  shrapnel  above  the  jaw  bone. 


over  it.  The  tube  is  then  moved  and  the  second  position  of  the  foreign 
body  noted.  It  is  then  a  matter  of  calculation  to  estimate  the  depth  of 
the  foreign  body.     Hampson  does  so  by  means  of  the  graduated  scale, 

Shenton  by  the  use  of  the  probe 
with  a  bulging  point  on  it,  and 
by  placing  the  limb  at  right 
angles  to  the  position  it  occu- 
pied when  the  mark  was  placed 
over  the  foreign  body. 

Localisation  of  Foreign 

Bodies  in  Deep  Parts  of  the 

Body. — In    several    of    these 

regions  the   locahsation  of    a 

foreign  body   is  a  matter   of 

extreme  difficulty,  notably  in 

the   thorax    abdomen,  pelvis, 

axilla   and  region  of  the  hip. 

The    exact    position    may    be 

marked  out  both  stereoscopi- 

cally  and  by  the  Mackenzie  Davidson  method,  and  yet  the  necessity  of 

avoiding  anatomical  structures  may  render  the  subsequent  removal  difficult. 

In  some  cases  it  may  be  helpful  to  take  a  lateral  view  of  the  thorax  or 


Fig.  99. — Fragment  of  shell  in  region  of  hip-joint. 


FOREIGN  BODIES  IN  THE  LIMBS  121 

spine.     This  may  enable  us  to  say  at  once  where  the  foieij^n    body  lies 


Fig.  100. — Fracture  of  tibia, 
portions  of  shell  in  limb. 


Fig.  101. — Fragments  of  bullet  in  limb  ;  arrows  indicate 
position  of  wounds.  Graduated  scale  over  bone.  Hori- 
zontal line  indicates  distance  from  edge  of  bone,  oblique 
line  distance  from  upper  arrow. 


in  relation  to  a  bony  landmark,  but  for  exact  localisation  it  is  necessary 

to    use    the    cross   thread  method. 

It  has  been  suggested  that  X-ray 

localisation    in    several    cases   bas 

complicated    the     removal    rather 

than   been    helpful.      In    order    to 

obviate     such     complications     the 

following  method  might  be  adopted. 

The  foreign  body  should  be 
accurately  located  by  the  Davidson 
method  and  stereoscopic  plates 
taken.  The  exact  spot  is  marked 
out  and  the  plates  viewed  in  the 
stereoscope.  These  two  give  the 
exact  spot  where  the  body  hes. 
For  removal  the  following  pro- 
cedure is  suggested. 

In  the  operating  theatre  or  the 
X-ray  room  a  simple  table  is  con- 
verted into  a  combined  X-ray  and 
operating-table  by  using  one  of  the 

simpler  tube-stands  which  allows  of  a  tube- carrier  being  placed  under 
the  table,  a  second  arm  carrying  the  fluorescent  screen.     The  latter  has 


Fig.  102. — Fragments  of  shrapnel  in  hand. 


122 


KADIOGRAPHY 


attached  to  it  a  small  scale  with  moving  points,  such  as  the  Hampson, 
or  one  made  by  Watson  and  Sons.  The  tube  is  accurately  centred  and 
the  distance  between  the  anti-cathode  and  the  screen  ascertained.  The 
patient  is  prepared  for  operation  and  placed  on  the  table.  The  body 
is  then  located  on  the  screen,  the  skin  being  marked  by  a  small 
incision  at  a  point  corresponding  to  the  shadow.  The  foreign  body 
lies  just  mider  this  spot.  The  depth  is  ascertained  by  a  displace- 
ment of  the  tube  a 
^li  known  distance,  the 

scale  on  the  screen 
automatically  record- 
ing the  depth  in  cen- 
timetres. This  read- 
ing should  be  com- 
pared with  the  result 
obtained  by  the  Mac- 
kenzie Davidson 
method,  and  if  they 
correspond  the  sur- 
geon has  an  accurate 
statement  of  the 
depth  of  the  foreign 
body.  If  owing  to 
the  anatomical  struc- 
tures interposed  on 
the  hne  of  the  body 
it  is  not  possible  to 
cut  straight  down 
into  it,  it  can  iii 
nearly  every  case  be 
found  by  probing.  Should  the  surgeon  fail  to  find  the  body  quickly, 
aimless  probing  should  not  be  continued.  The  hght  of  the  room  should  be 
excluded,  the  X-ray  tube  turned  on,  and  the  surgeon  will  at  once  be  able 
to  see  how  far  his  instrument  is  from  the  foreign  body  and  guide  his 
forceps  to  it. 

The  length  of  time  the  operator  is  exposed  to  the  rays  need  not  be  more 
than  a  few  seconds,  but  if  many  cases  daily  require  to  be  screened,  some 
method  of  protection  must  be  employed.  By  cutting  down  the  diaphragm 
so  that  only  a  small  pencil  of  rays  emerge  and  using  long-handled  instruments 
there  should  be  very  httle  risk  to  the  operator. 


Fig.  103.— Arrangement  of  X-ray  tube  and  fluorescent  screen  for 
accurate  localisation  by  screen  or  plate. 


RADIOGRAPHY  OF  THE  NORMAL  BONES  AND  JOINTS 

A  thorough  acquaintance  with  the  normal  appearance  of  these  parts  is 
necessary  on  the  part  of  the  radiographer  before  he  proceeds  to  an  interpreta- 
tion of  the  many  variations  which  he  may  be  called  upon  to  describe.  Not 
only  must  he  know  the  chief  bones  and  joints  from  any  one  aspect,  but  he 
should  by  a  careful  study  of  the  parts  know  them  from  any  point  of  view. 
It  may  not  be  always  possible  to  get  the  patient  into  the  position  of  ease  which 
is  generally  the  one  in  which  the  parts  can  be  radiographed  most  readily. 
A  patient  sufiering  from  an  injury  to  a  joint  may  not  always  be  able  to  take 
up  a  position  on  the  X-ray  table  which  will  enable  the  operator  to  radio- 
graph the  part  to  the  best  advantage ;  the  apparatus  may  have  to  be  adapted 
to  the  patient  instead  of  the  patient  to  the  apparatus,  hence  it  is  necessary 
that  the  operator  should  be  familiar  with  the  parts  from  several  points  of 
view.  In  ordinary  cases  of  fracture  of  the  bones  in  the  vicinity  of  a  joint  it  is 
always  a  good  rule  to  radiograph  the  parts  in  at  least  two  positions. 

The  Skull  and  Accessory  Sinuses 

There  are  several  positions  of  the  skull  which  lend  themselves  to  the 
production  of  good  radiographs.  Of  these  the  lateral  is  the  most  useful,  as 
it  gives  a  general  impression  of  the  whole  skuU  and  soft  parts,  the  articulations 
at  the  base,  and  a  lateral  view  of  the  cervical  vertebrae.  There  are  various 
modifications  of  this  position,  to  be  considered  in  detail  later,  which  are 
extremely  useful  when  special  areas  require  to  be  investigated.  To  get  good 
radiographs  of  the  skull,  it  is  essential  that  the  head  should  lie  fiat  on  one  side, 
and  be  held  absolutely  still  during  the  exposure.  A  useful  instrument  for 
fixing  the  skull  is  that  supplied  with  the  Sweet  localiser,  since  it  may  be  used 
in  all  positions  of  the  skull.  It  has  two  or  more  clamps  attached  to  a  base, 
upon  which  the  plate  may  be  placed.  These  clamps  keep  the  head  in  the 
same  position  while  several  radiographs  are  produced. 

Among  the  numerous  pieces  of  apparatus  which  can  be  used  for  the 
radiography  of  the  skull,  there  may  be  noted  a  simple  chair,  devised  by 
Dr.  Martin  Berry,  which  promises  to  answer  all  the  requirements  of  the 
radiographer.  This  apparatus  has  a  movable  back,  with  a  circular  hole 
in  it.  The  movement  is  in  the  vertical  direction,  to  adapt  the  central 
hole  to  the  varying  length  of  the  patient  when  seated  in  the  chair.  Side 
clamps  fix  the  head  after  the  necessary  angle  has  been  determined.  This 
angle  is  obtained  by  a  rod  moving  along  the  quadrant  of  a  circle.     The  head 

123 


124 


EADIOGEAPHY 


is  placed  to  correspond  with  the  angle  on  the  apparatus,  the  plate  being  placed 
always  at  the  same  angle  in  relation  to  the  tube.  An  efficiently  protected 
tube-box  is  placed  on  the  back  of  the  chair.  It  can  be  accurately  centred, 
and  has  both  vertical  and  transverse  movements  to  facihtate  rapid  adjustment 
behind  the  part  to  be  radiographed.  The  tube  always  occupies  the  same  re- 
lationship to  the  plate,  the  head  being  tilted  to  the  required  angle.  To  obtain 
a  picture  of  the  two  sphenoidal  sinuses  side  by  side,  a  plate  is  placed  under 
the  chin  and  the  tube  over  the  vortex  at  right  angles  to  the  plate.  A  film 
placed  in  the  mouth  well  backwards  under  the  head  and  soft  palate  will  give 
a  similar  picture.  Or  the  patient  may  he  on  a  couch  with  the  plate  under- 
neath and  a  compressor  extension  tube  brought  down  on  to  the  head  ;  this 
serves  the  double  purpose  of  fixing  the  head  and  cutting  ofi  secondary  radia- 
tions from  the  tube.  The  priaciple  of  the  compressor  tube  has  been  already  dis- 


FiG.  104. — Sweet  localiser. 


cussed.  Care  must  be  taken  to  see  that  the  long  axis  of  the  tube  is  parallel 
with  the  plate,  and  that  the  anti-cathode  of  the  tube  is  accurately  centred  in 
the  tube-box  before  the  tube  is  brought  into  position.  For  general  purposes  a 
central  position  of  the  tube  is  all  that  is  necessary,  the  anti-cathode  being 
over  the  centre  of  the  plate,  and  the  base  line  of  the  skull  corresponding  as 
nearly  as  possible  with  the  centre  line  of  the  plate  in  its  longest  diameter. 

The  base  line  of  the  skull  can  readily  be  determined  by  a  method  elabor- 
ated by  Dr.  E.  W.  A.  Salmond  and  the  author.  A  point  is  taken  on  the 
front  of  the  face  corresponding  to  the  nasion,  and  a  line  is  drawn  from  this 
point  backwards  through  the  external  auditory  meatus  to  the  occipital  bone, 
ending  in  the  vicinity  of  the  external  occipital  protuberance.  From  this 
line  as  a  base,  other  lines  may  be  drawn  perpendicularly  upwards  at  stated 


PLATE  I. — Normal  Skulls. 

a,  Lateral  view  of  normal  skull,  showing  frontal  sinuses,  sphenoidal  sinuses,  sella  turcica,  temporal  bones, 
cervical  vertebras,  and  lower  jaw. 

h,  Antero-posterior  view  of  adult  skull,  showing  frontal  sinuses,  orbits,  nasal  fossae,  antra,  etc.  Frontal 
.sinus  on  left  side  is  opaque. 

c,  Lateral  view  of  skull  to  show  the  sella  turcica,  articulation  of  spine  to  skull  ;  the  temporo- maxillary 
articulation  on  one  side  is  well  seen. 


KADIOGRAPHY  OF  THE  SKULL 


125 


intervals,  and  the  skull  divided  iato  three  or  more  sections,  these  perpendicu- 
lar lines  being  utilised  as  central  points  for  the  radiography  of  particular 
areas  of  the  skull  and  face.  The  most  useful  lines  are  those  drawn  at  the  half 
and  third  distances,  or  the  whole  line  may  be  divided  into  thirds  or  quarters. 
It  is  hardly  necessary  in  a  work  of  thLs  kind  to  describe  variations  of  this 
base  line,  but  for  practical  purposes  several  useful  methods  of  localisation 
of  areas  of  the  skull  will  be  described.     For  the  examination  of  the  mastoid 


Fig.  105. — Dr.  M.  Berry's  chair  for  frontal  sinuses,  etc. 

region  a  good  technique  has  been  described  by  Dr.  Howard  Pirie.     The 
following  is  the  technique  he  recommends  : 

Technique. — The  patient  should  he  prone  on  a  firm  couch.  The  head  is 
supported  on  an  inclined  plane^  making  an  angle  of  25  degrees  with  the  plane 
of  the  couch,  as  shown  in  Fig.  106.  The  photographic  plate  rests  on  this 
inchned  plane.  The  head  is  rotated  90  degrees  so  that  the  patient  looks  directly 
to  his  side ;  this  brings  the  mastoid  into  contact  with  the  plate.  The  pinna  of 
the  ear  is  turned  forward,  so  as  to  obscure  the  mastoid  as  little  as  possible.  The 
source  of  X-rays  is  placed  vertically  above  the  head,  and  the  perpendicular  ray 
is  made  to  fall  on  a  point  2  inches  above  the  highest  point  of  the  pinna.  The 
mastoid  on  each  side  must  be  skiagraphed  separately. 

The  glass  of  the  focus  tube  should  be  9  inches  away  from  the  hair.  The 
exposure  required  will  turn  a  Sabouraud  pastille  placed  at  2  centimetres  from 
the  glass  to  one-third  of  the  B  tint.     A  medium  hard  focus  tube  (4-5  Benoist), 


126 


EADIOGRAPHY 


with  30  milliamperes  for  fifteen  seconds  from  a  Snook  apparatus^  gives  a  plate 
wMch  should  be  fully  developed  in  seven  minutes  (Ilford  plate  and  developer). 

Skiagraphs  of  both  right  and  left  mastoids  must  be  made  of  every  case,  as 
a  single  skiagraph  of  one  mastoid  is  of  little  value.  A  different  focus  tube 
should  be  used  for  each  mastoid,  as  it  is  rarely  possible  to  get  one  tube  to  remain 
constant  in  vacuum  for  both  exposm-es.  Both  focus  tubes  must,  of  course,  be 
of  the  same  hardness.  This  is  one  of  the  most  important  points  in  the  technique 
■ — viz.,  to  have  two  similar  tubes  of  equal  hardness  and  quality.  The  American- 
made  tubes  lend  themselves  to  this  better  than  any  others  I  have  used. 

Having  secured  radiographs  of  both  right  and  left  mastoids,  one  should 
place  them  side  by  side  in  a  viewing-box,  and  note  any  differences.  The  radio- 
graph should  show  : 

1.  The  articulation  of  the  lower  jaw,  and  the  posterior  border  of  the  ascend- 
ing ramus  of  the  jaw. 

2.  The  auditory  canal,  placed 
behind  the  articulation  of  the  lower 
jaw,  and  separated  from  it  by  about 
one-quarter  of  an  inch. 

3.  The  air  cells,  which  form  a 
reticulum  extending  from  the  articula- 
tion of  the  jaw  backwards.  The  cells 
usually  appear  larger  in  the  lower 
part,  and  smaller  above.  Sometimes 
they  extend  forwards  above  the 
articulation  of  the  jaw  into  the  base 
of  the  zygoma.  It  should  be  remem- 
bered that  the  cells  extend  well  behind 
the  limit  of  the  mastoid  process. 

4.  The  petrous  bone  surrounding 
the  auditory  canal,  appearing  as  a 
dense  area  superimposed  on  the 
mastoid  cells. 

5.  The  outline  of  the  lateral 
sinus  should  be  faintly  indicated 
running  through  the  posterior  half  of 
the  cells. 

6.  The  foramen  magnum,  appear- 
ing as  an  elliptical  opening  with  part  of  the  first  vertebra  crossing  it. 

7.  The  outline  of  the  pinna  of  the  ear. 
Acute  mastoiditis  shows  the  following  departures  from  the  above  description  : 

1.  The  air  cells  are  obscured,  but  can  still  be  faintly  seen. 

2.  The  outline  of  the  lateral  sinus  may  be  a  little  more  defined  than  normally. 

3.  The  petrous  bone  is  denser. 

4.  The  whole  mastoid  region  is  denser. 

When  one  gets  an  absolutely  normal  mastoid  on  one  side,  and  the  other 
side  presents  the  appearance  just  described,  together  with  certain  clinical  signs 
and  symptoms,  one  is  justified  in  diagnosing  acute  mastoiditis. 

Chronic  mastoiditis  is  very  typical  in  a  skiagraph.  It  presents  the  following 
departures  from  the  normal : 

1.  The  air  cells  are  completely  absent. 

2.  The  petrous  bone  stands  out  as  a  very  dense,  roughly  triangular  area, 
with  its  apex  pointing  upwards  and  backwards. 

3.  The  posterior  border  of  the  petrous  bone  forms  part  of  a  sharp  crescent- 


FiG.  106.- 


-Positioii  for  nidiograpliy  of  the  mastoid 
sinuses.     (Pirie. ) 


PLATE  II. — Normal  Skulls. 

a.  Skull  of  child,  plate  on  anterior  aspect  showing  nasal  fossae  ;  teeth  well  shown  ;  there  are  several 
iinerupted  teeth  seen. 

6,  Mid  area  of  skull  ;  a  line  has  been  placed  on  points  giving  the  radiographic  base-line  ;  the  line 
runs  through  the  base  of  the  sella  turcica  (dry  skull). 

c,  Lateral  view  of  skull  in  living  subject ;  probes  have  been  placed  in  the  frontal  and  sphenoidal  sinuses. 


RADIOCJKAPHY   OF  THE  FRONTAL  SINUSES 


127 


shaped  line.     Tliis  crescent-shaped  line  corresponds  with  the  upper  and  anterior 
border  of  the  lateral  sinus. 

4.  Tlie  lateral  sinus  is  fi-efjuently  very  well  shown. 

(1)  Radiography  of  the  Sella  Turcica.-  A  useful  method  for  the 
radiography  of  the  sella  turcica  has  been  described  by  Dr.  Finzi.  The 
patient  is  placed  upon  the  couch  and  the  tube  centred  from  below.  To  deter- 
mine the  exact  position  two  small  coins  are  placed  one  in  each  ear.  After 
these  are  superimposed  under  the  screen,  the  tube  is  then  moved  upwards  and 
forwards  1  inch  in  each  direction,  and  the  radiograph  taken.  A  perfect 
picture  of  the  area  required  should  be  obtained. 

When  radiographing  particular  areas  of  the  skull,  the  diaphragm  should 
be  shut  down  to  the  smallest  possible  size,  or  if  the  tube  ls  used  overhead  a 
small  extension  tube  should  be  inserted  between  the  tube  and  the  patient. 
Pictures  obtained  in  this  way  will  be  found  to  give  much  finer  detail  than 
those  taken  with  a  wide  diaphragm.  It  is  important  to  note  that  in 
radiographs  of  the  skull  as  much  detail  as  can  be  obtained  is  desirable. 

(2)  The  Examination  of  the  Frontal  Air  Sinuses. — Two  methods 
may  be  employed  :  (a)  a  lateral  view  of  the  skull,  showing  the  air  sinuses  in 
profile  ;  (6)  antero-posterior,  the  plate  on  the  front  of  the  skull  and  the  tube 
behind.  A  direct  antero- 
posterior view  does  not 
show  the  sinuses  at  all 
well,  the  overlapping  of 
the  shadow  caused  by  the 
occipital  and  temporal 
bones  obscuring  the  detail 
in  the  frontal  and  acces- 
sory sinuses.  There  are 
two  routes  by  which  the 
rays  may  be  passed  through 
the  back  of  the  skull.  (1) 
The  tube  may  be  centred 
below  the  bony  mass 
formed  by  the  occipital 
protuberance  :  we  still 
have  to  traverse  the  thick 
parts  of  the  base  of  the 
skull.  (2)  A  better  method 
is  to  place  the  patient  face 
downwards  on  the  photo- 
graphic plate,  the  latter 
being  placed  at  an  angle 
of  25  degrees.     The  tube 

is    centred     well     in     front  Combined  chair  with  clamps  for  flxation  of  the  head  and  an 

adaptable  plate-holder. 

of  the  occipital  protuber- 
ance, and  an  oblique  though  somewhat  distorted  view  is  obtained  which 


Fig.  107. — Chair  for  cranial  radiography. 


128 


EADIOGKAPHY 


shows  the  frontal  air  sinuses  well.  Plate  I.,  showing  frontal  air  sinuses, 
taken  by  this  method,  illustrates  the  points  to  be  examined. 

(3)  For  the  Examination  of  the  Sphenoidal  Sinuses,  the 
Ethmoidal  Sinuses,  and  the  Turbinate  Bones,  a  plate  is  fixed  on  the  front 
of  the  face,  and  the  tube  centred  just  a  little  below  the  occipital  protuberance. 
This  position  should  also  show  the  bones  of  the  face  and  the  maxillary  antrum. 
The  teeth  are  also  well  demonstrated.  The  condyles  of  the  jaw  and  the  an- 
terior view  of  the  tempero-maxillary  articulation  are  also  seen,  while  behind 
and  a  little  external  is  the  mastoid  process,  with  its  air  cells  clearly  shown. 

Plate  I.,  representing  a  normal  skull  taken  in  the  lateral  position,  shows 


Fig.  108. — Chair  for  cranial  radiography. 

all  the  important  structures  at  the  base  of  the  skull ;  the  three  levels  are  well 
shown,  and  the  various  air  sinuses  are  distinctly  seen,  notably  the  frontal 
air  sinuses.  Taking  the  bones  of  the  skull  from  before  backwards,  one  sees 
the  orbital  plate  of  the  frontal  bone,  the  anterior  clinoid  process,  the  sella 
turcica,  the  posterior  clinoid  process  standing  well  in  relief ;  extending 
backwards,  the  petrous  portion  of  the  temporal  bone  appears  as  a  denser 
irregular  shadow  ;  and,  immediately  behind,  the  mastoid  air  cells  are  promi- 
nently shown.  Then,  at  the  posterior  portion,  the  well-marked  depression 
formed  by  the  occipital  bone  is  shown.  The  thickness  of  the  bony  wall  of 
the  section  of  the  skull  shows  the  two  layers  of  bone  with  the  cancellous 
bone  between  them. 


PLATE  III. — Skulls  showing  Departures  from  the  Normal. 


a,  Lateral  view  of  skull,  showing  erosion  of  occipital  bone  the  result  of  injury  with  secondary 
■disease  of  bone.     Note  large  frontal  sinuses. 

b,  Skull  in  a  child,  showing  moulding  of  the  cranial  bones  resulting  from  intracranial  pressure. 

c,  Skull  from  a  case  of  tumour  of  the  brain,  situated  at  the  sella  turcica  ;  the  detail  in  the 
region  is  lost. 


PLATE  IV. — Lower  Jaw  and  Cervical  Region. 


a,  Dentigerous  cyst  iu  lower  jaw  (buried  tooth). 
6,  Fracture  through  ramus  of  lower  jaw. 
Skull  showing  good  detail  in  soft  parts,  absence  of  teeth,  calcified  cervical  glands. 
d,  Bismuth  food  in  stricture  at  upper  end  of  oesophagus. 


THE  LOWER  JAW  .  129 

In  the  region  of  the  neck  the  cervical  vertebrae  are  shown  lq  profile,  the 
styloid  process  extending  downwards  and  forwards  between  the  cervical 
vertebrae  and  the  descending  ramus  of  the  lower  jaw.  The  zygomatic  arch 
is  seen  extending  forwards  on  the  lateral  aspect  of  the  face.  The  superior 
maxilla  gives  an  irregular  shadow  and  the  anterior  shows  a  clear  space,  the 
nasal  bones  are  faintly  outlined  in  profile,  and  the  lower  jaw  is  also  shown  in 
its  lateral  aspect. 

(4)  The  Lower  Jaw  is  an  important  bone,  and  rather  difficult  to  demon- 
strate satisfactorily.  It  may  be  shown  by  two  methods  :  (a)  showing  the 
whole  of  the  bone  in  a  skiagram  of  the  face  ;  (6)  portions  of  the  bone  may  be 
demonstrated  by  placing  a  film  inside  the  mouth  agaiast  the  part  of  the  bone 
it  is  necessary  to  show,  and  using  the  focus  tube  outside.  The  picture  then 
obtained  is  a  small  one,  but  quite  large  enough  to  show  a  fracture,  an  abscess, 
or  disease  or  damage  to  a  tooth  and  its  socket.  The  tempero-maxUlary  articu- 
lation of  either  side  can  be  satisfactorily  shown  by  centering  the  tube  behind 
and  a  little  below  the  angle  of  the  jaw  on  the  more  distant  aspect  from  the 
plate, 

Plate  I.,  Fig.  h  shows  the  chief  bony  points  of  the  skuU  and  face  taken 
from  the  antero-posterior  position.  The  plate  was  placed  on  the  face,  with 
the  focus  tube  behind.  The  orbits  are  well  marked,  and  the  nasal  cavities 
show  a  considerable  amount  of  detail,  which  is  of  great  value  when  one 
has  to  consider  the  possibility  of  fracture  in  these  regions.  The  antrum  of 
Highmore  is  clearly  defined,  the  zygomatic  arch  stands  out  prominently, 
the  lower  jaw  is  thrown  out  in  relief,  and  behind  there  is  a  distinct  picture 
of  the  mastoid  portion  of  the  temporal  bone  with  the  air  cells. 

Plate  I.,  Fig.  c  shows  a  small  and  more  distinct  view  of  the  central 
portion  of  the  bony  parts  of  the  skull.  The  points  to  observe  are  the  levels 
of  the  bone  of  the  skull  in  relation  to  the  exterior,  the  clinoid  processes  with 
the  sella  turcica  between,  the  relation  of  the  chief  sutures  to  the  various  levels, 
and  the  well-marked  grooves  in  the  inner  table  of  the  skull  for  blood-vessels. 
A  clearly  defined  shadow  is  thrown  by  the  pituitary  body  situated  in  the  sella 
turcica.  The  cervical  vertebrae  in  relation  to  the  bone  of  the  skull  show  up 
well.  The  condyle  of  the  lower  jaw,  situated  in  its  articular  cavity,  is  also 
evident,  and  a  fairly  good  idea  of  the  general  contour  of  the  latter. 

(5)  The  Examination  of  the  Mouth,  and  especially  the  Teeth,  is 
one  which  calls  for  special  attention.  The  general  outline  can  be  obtained 
by  plates  placed  on  the  exterior,  the  tube  being  angled  to  prevent  overlapping 
of  the  shadows  produced  by  the  two  sides.  Better  results  can  be  obtained 
when  films  are  placed  in  the  interior  of  the  mouth  against  the  area  required, 
the  tube  being  centred  over  the  film  from  the  outside.  A  suitable  mouth  gag 
may  be  used  ;  this  possesses  the  great  advantage  of  preventing  movements 
during  the  exposure  ;  a  piece  of  cork  or  a  towel  rolled  up  tight  is  also  very 
efficacious  when  other  appliances  are  not  at  hand. 

Special  appliances  have  been  devised  for  the  retention  of  the  film  in  the 
mouth.  A  suitably-shaped  cork  is  provided  with  a  slot,  into  which  various 
rectangular  plates  of  metal  are  slipped.    These  metal  plates  are  soft,  and  can 

9 


130 


EADIOGEAPHY 


be  bent  into  any  curve  to  suit  the  contour  of  the  mouth,  and  thus  secure  a 
close  contact.  The  films  are  wrapped  up  in  paper  as  usual,  with  a  small 
loop  of  paper  left  at  the  back,  which  is  slipped  over  the  metal  plate,  so  that 
any  curve  to  which  the  plate  is  bent  also  carries  the  film  with  it. 

The  cork  is  gripped  in  the  mouth  by  the  patient,  it  being  obvious  that 
this  method  enables  the  film  to  be  held  in  any  position  inside  the  mouth 
without  any  further  device  or  support. 


The  Cervical  Region 

The  best  positions  in  which  to  radiograph  this  area  are  :   (1)  The  antero- 


FiG.  109. — Upper  cervical  region,  antero-posterior  view. 
Taken  with  plate  behind  and  an  extension  tube  in  front  of  the  open  mouth. 

posterior,  and  (2)  the  lateral.  The  antero-posterior  is  comparatively  easy  in 
the  lower  two-thirds.  AVhen  the  patient  is  placed  with  the  posterior  aspect 
on  the  plate  and  the  tube  centred  over  the  middle  of  the  plate,  a  view  is  ob- 
tained of  the  whole  of  the  cervical  vertebrae  and  the  upper  dorsal,  the  apices 
of  the  lungs  coming  into  the  picture,  as  do  also  the  sternal  ends  of  the  clavicles 
and  the  manubrium  sterni.  The  upper  cervical  vertebrae  are  obscured  by 
the  basi  occiput  and  the  lower  maxilla. 

Should  it  be  necessary  to  obtain  an  impression  of  the  first  three  cervical 
vertebrsB,  other  methods  must  be  adopted.     The  base  of  the  occiput  and  the 


THE  CERVICAL  REGION 


131 


first  and  second  cervical  vertebrae  may  be  examined  by  placing  a  plate  on 
the  posterior  aspect ;  and  by  using  a  small  extension  tube,  with  the  mouth 
opened  to  its  widest  extent,  a  good  radiograph  may  be  obtained  which  should 
show  the  condyles  of  the  occipital  bone,  the  odontoid  process  of  the  axis, 
the  atlas,  and  the  third  cervical  vertebra. 

The  lateral  view  of  the  cervical  area  shows  the  whole  region  from  the 
occiput  down  to  the  upper  dorsal  vertebrae.  This  is  a  good  method  for 
ascertaining  the  condition  of  the  bodies  of  the  cervical  vertebrae,  the  integrity 
of  the  spinal  canal,  and  the  presence  of  abnormalities  of  the  region.  The 
presence  of  cervical  ribs  can  best 
be  shown  by  the  antero-posterior 
position. 

The  cervical  region  has  been 
partially  shown  in  Fig.  109,  but 
it  is  necessary  to  illustrate  this 
particular  region  fully,  for  it  is 
here  that  the  difficulty  of  show- 
ing a  fracture  or  dislocation  may 
be  very  great,  and  in  some  in- 
stances impossible. 

An  antero-posterior  view  of 
the  neck  region  is  not  a  very 
satisfactory  one,  because  of  the 
superimposing  of  the  occipital 
region  and  the  lower  jaw.  In 
cases  where  it  is  desirable  to  show 
the  atlas  and  axis,  and  the  articu- 
lation between  the  former  and  the  occipital  bone,  it  is  necessary  to  take  the 
skiagram  through  the  open  mouth,  as  described  in  detail  above.  The 
resulting  picture  is  necessarily  small,  but  large  enough  to  include  the 
parts  desired. 

The  position  usually  taken  is  the  lateral  one,  with  the  head  rotated 
towards  the  plate.  It  is  then  possible  to  get  a  fairly  good  outline  of  the  seven 
cervical  vertebrae  and  the  adjacent  portions  of  the  base  of  the  skull.  The 
bodies  of  the  cervical  vertebrae  are  readily  shown,  but  to  get  accurate 
outlines  the  head  must  not  be  moved  to  either  side. 


Fig.  110. — Normal  cervical  and  upper  dorsal  region 
showing  the  sterno-clavicular  articulation.  This 
position  is  useful  when  examinations  for  cervical  ribs 
have  to  be  made. 


The  Bones  of  the  Chest 

The  Clavicles  may  be  examined  in  their  entire  length,  or  in  sections  when 
the  shoulder  or  upper  thorax  are  in  the  picture.  The  patient  is  placed  with 
the  plate  on  the  front  of  the  chest,  and  the  tube  is  operated  either  from  below 
or  from  above,  whichever  is  the  more  convenient. 

The  Sternum  has  often  to  be  examined,  the  position  in  which  it  is  usually 
taken  being  from  behind  forwards.  The  picture  is  usually  confused  by  the 
shadows  of  the  mediastinum  and  spinal  column.     An  oblique  lateral  view 


132  EADIOGEAPHY 

of  tlie  thorax  enables  us  to  examine  the  whole  of  the  sternum  with  its  articula- 
tions. The  picture  is  naturally  somewhat  distorted,  but  nevertheless  a  good 
idea  may  be  obtained  of  its  condition,  injuries  and  tumours  being  readily 
shown.  The  ribs  can  be  shown  in  these  positions,  the  lateral  position 
showing  the  ribs  in  their  entirety. 

The  Dorsal  Spine 

Two  methods  are  used  here  :  (1)  an  antero-posterior,  with  the  plate  on 
the  posterior  aspect  of  the  spine ;  (2)  a  direct  lateral  view.  The  latter  may  be 
obtained  by  placing  the  plate  on  one  side  and  the  tube  on  the  other,  the  arms 
being  extended  above  the  head,  to  get  rid,  so  far  as  is  possible,  of  the  shadows 
of  the  scapulae.  The  bodies  of  the  vertebrae  are  then  well  seen,  as  is  also  the 
posterior  portion  of  the  column  with  the  transverse  process,  the  laminae, 
and  spines  of  the  vertebrae.     The  spinal  canal  can  also  be  seen  in  the  plate. 

In  taking  the  antero-posterior  view,  it  is  well  to  have  the  tube  a  good 
distance  away  from  the  plate,  the  greater  the  distance  the  better  being  the 
detail  shown  in  the  bones.  The  exposure  has  to  be  proportionately  pro- 
longed, and  if  the  tube  is  soft  a  longer  exposure  is  further  necessary.  In 
examining  the  spine  of  children  for  curvature,  etc.,  the  author  obtains  good 
pictures  by  placing  the  tube  four  or  five  feet  from  the  plate. 

Stereoscopic  radiographs  should  always  be  taken  of  these  spinal  cases, 
as  much  more  detail  can  be  shown  when  they  are  examined  in  a  stereoscope. 
This  method  is  most  useful  in  extensive  caries  of  the  spine  when  there  is 
considerable  deformity,  as  the  picture  is  sharp,  and  fine  changes  in  the  bones 
can  be  detected.  When  the  spine  alone  is  required  the  diaphragm  of  the 
tube  box  should  be  closed  down  in  order  to  get  a  long,  narrow,  slit-like 
aperture ;  this  ensures  better  detail  in  the  parts  required. 

The  Lumbar  Spine 

This  is  radiographed  in  the  antero-posterior  position,  from  the  lower 
dorsal  to  the  sacrum,  by  using  a  large  extension  tube  with  compression  of  the 
abdominal  contents.  It  is  an  advantage  in  all  positions  of  the  spine,  thorax, 
and  abdomen,  to  diminish  the  movements  of  the  parts  as  much  as  possible. 
The  methods  of  compression  employed  are  various.  If  working  from  below, 
it  is  an  easy  matter  to  have  some  simple  form  of  compressor  attached  to  the 
upper  aspect  of  the  couch.  An  air-cushion  is  placed  between  the  patient 
and  the  couch  to  compress  the  abdominal  contents.  When  using  the  tube 
above  the  couch,  the  compression  may  be  obtained  by  fastening  stout  linen 
bands  to  the  couch,  carrying  them  round  the  patient,  and  fixing  on  the  op- 
posite side.  A  long  extension  tube  may  be  attached  to  the  tube-holder,  and 
fixed  down  on  the  patient  by  a  mechanical  device.  These  are  all  matters 
of  detail  which  can  be  arranged  to  suit  the  individual  worker,  but  whichever 
method  is  employed  there  can  be  no  question  of  the  great  advantages  of 
compression. 


PLATE  V. — Normal  Lumbar  Spine  and  Pelvis. 


a.  Normal  lumbar  spine. 
h.  Normal  male  pelvis, 
c,  Normal  female  pelvis. 


THE  UPPER  EXTREMITY  133 


The  Pelvis 


This  region  often  requires  most  careful  examination,  for  injuries,  disease, 
or  calculi.  The  positions  are  again  two,  antero-posterior  and  postero- 
anterior,  both  being  useful.  To  get  fine  detail  of  the  sacrum  an  extension 
tube  is  used,  and  it  should  be  pressed  well  down  into  the  pelvic  cavity.  The 
whole  pelvis,  with  the  heads  of  the  femora  and  the  acetabula,  can  be  obtained 
by  using  a  large  plate  behind  the  patient,  or  by  placing  the  patient  on 
the  anterior  surface  with  the  plate  underneath,  the  tube  being  placed 
above  the  posterior  aspect  of  the  patient.  For  the  examination  of  the 
coccyx  a  small  extension  tube  should  be  used,  and  the  tube  tilted  forward 
into  the  cavity  of  the  pelvis,  the  plate  being  placed  on  the  posterior  aspect 
beneath  the  patient. 

The  Upper  Extremity 

The  Examination  of  the  Clavicle. — The  clavicle  requires  to  be  con- 
sidered in  its  whole  length.  Either  extremity  will  appear  in  radiographs  of 
the  shoulder  and  of  the  thorax.  The  external  end  has  frequently  to  be 
examined  for  displacements  and  injuries.  The  acromial  end  of  the  clavicle 
is  seen  in  the  several  plates  illustrating  the  shoulder-joint. 

Examination  of  the  Shoulder-joint. — The  shoulder- joint  calls  for 
minute  description.  It  is  frequently  injured,  and  should  be  carefully  exam- 
ined in  all  cases  of  suspected  injury  to  that  region.  It  is  usually  examined 
in  the  antero-posterior  position,  first  with  the  plate  on  the  posterior  aspect 
of  the  joint  with  the  tube  in  front,  and  then  with  the  plate  placed  on  the 
anterior  aspect  with  the  tube  behind.  It  should  always  be  examined  in  these 
two  positions,  if  one  is  to  demonstrate  an  injury  in  the  shoulder-joint. 
The  anti-cathode  should  be  centred  as  nearly  as  possible  over  the  coracoid 
process.  An  extension  tube  should  be  used,  and  slight  pressure  applied  to 
the  part.  The  pictures  obtained  by  these  two  positions  differ  in  several 
points  of  detail,  the  difierences  being  readily  seen  when  the  two  radiographs 
are  compared.  The  anatomical  points  seen  in  the  pictures  should  be — (1)  the 
head  of  the  humerus  ;  (2)  the  glenoid  cavity  ;  (3)  the  axillary  border  of  the 
scapula;  (4)  the  coracoid  process ;  (5)  the  acromion  process ;  (6) the  acromial 
end  of  the  clavicle.  It  is  usual  in  such  examinations  to  have  the  arm  by 
the  side.  Supplementary  skiagrams  can  be  obtained  by  extending  the  arm 
out  from  the  side  or  carrying  it  directly  upwards  in  line  with  the  long  axis 
of  the  body.  When  it  is  necessary  to  examine  the  tuberosities  the  arm  may 
be  rotated  in  the  direction  necessary  to  show  either  one.  Should  the 
axillary  border  be  suspected,  the  arm  should  be  carried  upwards  and 
forwards  and  rotated  outwards,  so  as  to  bring  the  body  of  the  scapula  away 
from  the  trunk. 

Plate  VI.,  Fig.  h  shows  the  appearance  of  the  parts  when  the  plate  is 
placed  on  the  anterior  aspect  of  the  joint. 

The  acromion  process  is  best  shown  when  the  plate  is  placed  on  the 


134  EADIOGEAPHY 

posterior  aspect  of  tlie  joint,  with  the  tube  in  front,  it  beiag  then  possible  to 
demonstrate  the  whole  of  the  process  and  the  spiae  of  the  scapula,  while  the 
infra-  and  supra-spinous  fossae  can  also  be  shown  in  their  entirety.  The 
coracoid  process  is  well  seen  in  all  of  the  shoulder  negatives,  and  changes 
in  its  position  can  be  shown,  fractures  being  readily  demonstrated. 

When  fine  detail  is  necessary,  and  an  injury  is  known  to  exist  in  the 
region  of  the  coracoid  process,  a  small  picture  should  be  obtained,  an  exten- 
sion tube  being  centred  over  the  process,  and  the  plate  being  either  on  the 
posterior  or  anterior  aspect  of  the  joint.  The  greater  tuberosity  of  the 
humerus  will  be  clearly  shown.  Its  position  and  appearance  will  vary  with 
the  position  of  the  shaft  of  the  bone  at  the  time,  as  regards  rotation  outwards 
or  inwards.  With  the  arm  abducted  and  carried  over  the  head,  the  shoulder- 
joint  alters  considerably  in  appearance.  The  head  of  the  humerus  and  the 
glenoid  cavity  are  well  demonstrated,  and  the  coracoid  process  is  also  well 
seen. 

The  spine  and  body  of  the  scapula  are  often  investigated  for  evidence  of 
fracture  or  tumour.  The  bone  shows  well  in  any  of  the  usual  positions,  but 
if  the  vertebral  border  is  under  inspection,  it  is  necessary  to  take  a  plate  with 
the  patient  lying  on  it,  and  the  arm  abducted  and  carried  upwards  towards 
the  head. 

The  Elbow-joint. — Four  positions  are  available  in  this  joint,  and  each 
may  be  modified  by  the  position  in  which  the  limb  is  placed  at  the  time. 

(1)  Antero-posterior,  with  plate  on  the  front  of  the  limb. 

(2)  Antero-posterior,  with  plate  on  the  back  of  the  limb. 

(3)  Lateral  internal,  with  plate  on  the  inner  aspect  of  the  joint,  the  arm 
being  either  flexed  or  extended. 

(4)  Lateral  external,  plate  on  outer  aspect  of  the  joint,  the  forearm 
flexed  or  extended. 

Good  pictures  of  the  head  of  the  radius  and  its  articulation  can  be 
obtained  by  slightly  flexing  and  pronating  the  forearm. 

The  Radius  and  Ulna  should  always  be  taken  in  two  positions  :  (1) 
lateral,  (2)  antero-posterior. 

The  Wrist-joint  must  always  be  examined  in  two  planes,  the  antero- 
posterior and  the  lateral.  In  both  positions  the  tube  is  centred  over  the 
carpus.  Compression  on  the  limb  may  be  effected  by  using  a  long  extension 
tube,  pads  of  lamb's  wool  being  applied  over  the  part,  or  sand-bags  may  be 
used  to  steady  the  limb. 

Metacarpal  Bones  and  Phalang-es. — These  frequently  call  for  care- 
ful examination.  Antero-posterior  and  lateral  pictures  may  readily  be 
obtained,  but  lateral  pictures  of  the  middle  metacarpal  bones  are  very 
difficult  to  obtain.  The  hand  is  placed  obliquely  on  a  plate,  and  the  tube 
directed  well  in  front  of  the  middle  line.  The  picture  is  somewhat  distorted. 
Lateral  views  of  the  phalanges  can  be  procured  by  placing  a  plate  between 
the  fingers. 


PLATE  YI. — Normal  Shoulder-joint. 

«,  Normal  shoulder -joint,  plate  on  posterior  aspect  of  joint. 

b.  Normal  shoulder-joint,  plate  on  anterior  aspect. 

c.  Normal  shoulder-joint,  arm  abducted. 


THE  LOWER  EXTREMITY  135 

The  Lower  Extremity 

The  bones  of  the  pelvis  are  seen  in  most  of  the  radiographs  taken  for  the 
bladder  and  ureters.  The  sacrum  is  readily  shown  by  putting  a  plate  beneath 
the  patient,  and  using  a  compression  tube  from  above.  In  large  pictures  of 
the  region  the  acetabula  with  the  head  of  the  femur  are  well  shown. 

When  the  two  joints  are  required  for  comparison,  a  good  method  is  to 
radiograph  the  lower  pelvis,  centering  the  tube  just  below  the  symphysis 
pubis.  Good  detail  is  obtained  of  the  head  of  the  bones,  and  a  good  outline 
of  the  acetabulum. 

The  iliac  bones,  which  often  require  to  be  radiographed  for  fracture, 
tumour,  etc.,  may  be  examined  in  two  positions,  with  the  tube  centred  over 
the  middle  of  each  bone,  from  the  front. 

The  Hip-joint  is  probably  one  of  the  joints  most  frequently  examined. 
Two  positions  are  available  : 

(a)  The  posterior,  when  the  plate  is  placed  below  the  patient  and  the 
tube  centred  over  the  head  of  the  bone. 

(6)  The  anterior,  with  the  plate  on  the  front  of  the  joint  and  the  tube 
centred  behind. 

Both  are  useful,  and  either  may  give  valuable  information.  The  im- 
portant point  is  to  make  sure  that  good  detail  is  obtained.  This  joint  is  the 
most  difficult  of  all  the  joints  from  which  to  obtain  good  radiographs. 

A  third  position  has  already  been  described,  where  the  plate  is  behind 
the  patient  and  the  tube  centred  just  above  the  symphysis  pubis. 

However  obtained,  a  good  radiograph  should  show  the  head  of  the  femur, 
the  cotyloid  notch  should  be  visible,  the  rim  of  the  acetabulum  should  be 
seen  superimposed  over  the  head  of  the  bone,  and  in  normal  joints  the  inter- 
articular  space  should  be  shown.  The  picture  should  include  the  greater  and 
lesser  trochanter  and  the  upper  third  of  the  shaft  of  the  femur.  The  ischium 
and  pubis  should  come  into  the  picture,  as  should  also  the  lower  half  of  the 
ilium.  In  some  instances  the  limb  may  be  abducted  and  rotated  outwards 
to  throw  the  head  of  the  femur  into  prominence. 

The  Shaft  of  the  Femur  may  be  taken  in  two  directions,  antero- 
posterior and  lateral.  Only  the  lower  two-thirds  can  be  seen  in  the  latter 
position.  When  the  whole  bone  is  required  long,  narrow  plates  must  be 
used,  the  tube  requiring  to  be  centred  at  a  longer  distance,  in  order  to  get  the 
whole  of  the  bone.  The  lateral  view  of  the  femur  may  be  taken  from  either 
side. 

The  Knee-joint. — This  important  joint  requires  careful  examination. 
(a)  Both  knee-joints  may  be  taken  on  one  plate.  The  tube  is  centred  over 
the  space  between  the  two  joints,  and  either  an  anterior  or  posterior  view  may 
be  obtained,  (6)  Plate  on  posterior  aspect  of  joint,  tube  in  front,  (c)  Plate 
on  anterior  aspect,  tube  behind.  The  patella  is  well  seen  by  this  method  of 
examination. 

For  the  patella  alone,  the  plate  is  placed  on  the  front  and  the  tube  centred 
just  outside  the  external  border  of  the  shaft,  and  directed  obliquely  down- 


136  EADIOGEAPHY 

wards  to  avoid  the  shadow  of  the  femur  obscuring  that  of  the  patella.  Plates 
taken  in  this  position  give  good  detail  of  the  component  parts  of  the  joint. 
Fine  detail  should  always  be  aimed  at  in  these  examinations.  It  is  often 
possible  to  show  apparently  slight  injury  to  the  bone  without  an  actual 
fracture.  At  a  later  date  this  may  become  the  seat  of  chronic  inflammatory 
changes,  or  tuberculosis  of  a  joint  may  be  a  sequel  to  such  an  injury. 

The  points  to  observe  are  the  general  contour  of  the  articular 
surface,  and  the  space  between  the  condyles,  which  is  usually  occupied 
by  cartilage,  but  which  frequently  does  not  show  any  detail  of  the 
articular  surface,  though  plates  taken  with  a  very  soft  tube  show  shadowy 
detail  of  the  cartilages  and  the  softer  structures  of  the  joint.  The  normal 
position  of  the  patella,  the  articular  surface  of  the  upper  end  of  the  tibia, 
and  the  spine  of  the  tibia  should  be  noted.  This  is  of  great  importance, 
for  when  cases  are  examined  for  injuries  of  the  joint  we  must  not  overlook 
the  relations  of  these  parts  to  one  another. 

(d)  The  lateral  view  of  the  knee-joint  is  the  most  useful  one  from  the 
point  of  view  of  diagnosis.  In  it  we  see  the  relations  of  the  bony  surfaces  and 
a  faint  line  of  the  articular  cartilage,  while  in  some  instances  the  shadow  of 
the  internal  articular  cartilage  is  seen  in  a  very  faint,  somewhat  striated 
shadow.  The  outline  of  the  patella  is  sharp  and  clearly  cut,  the  pad  of  fat 
below  the  patella  is  frequently  shown,  and  the  Ugamentum  patellae  can  be 
traced  from  the  lower  edge  of  the  patella  to  its  insertion  into  the  tuberosity 
of  the  tibia.  The  two  condyles  of  the  lower  end  of  the  femur  are  clearly 
seen,  and  the  head  of  the  fibula  with  its  articulation  to  the  tibia  is  also 
shown.  This  view  of  the  knee-joint  may  be  taken  from  either  side — internal 
or  external. 

The  Tibia  and  the  Fibula. — These  bones  may  be  radiographed  from  the 
front  or  the  back,  or  laterally,  from  the  inner  or  outer  aspects  of  the  limb. 

The  Ankle-joint. — There  are  four  positions  for  the  examination  of 
this  joint : 

(a)  Anterior,  plate  on  the  front  of  the  limb. 

(6)  Posterior,  plate  on  the  posterior  aspect  of  the  limb,  the  foot  at  right 
angles  to  the  leg. 

(c)  Lateral  internal. 

(d)  Lateral  external. 

The  Bones  of  the  Foot :  Tarsal,  Metatarsal,  and  Phalang-es. — 
For  a  general  survey  of  the  foot,  the  plate  may  be  placed  upon  the  inner  aspect 
and  the  tube  centred  over  the  mid-point  between  the  os  calcis  and  the  end  of 
the  toes. 

By  making  another  exposure  the  outer  aspect  of  the  foot  may  be  brought 
into  closer  contact  with  the  plate. 

The  OS  calcis  can  be  examined  in  three  positions  : 

(1)  In  the  lateral  position,  plate  on  outer  aspect  of  foot 

(2)  Lateral  aspect,  plate  on  inner  side  of  the  foot. 

(3)  With  a  plate  placed  mider  the  foot,  the  patient  standing  upon  it, 
the  tube  being  centred  behind  the  bone,  well  above  the  insertion  of  the  tendo 


THE  FOOT  137 

Acliillis,  and  directed  obliquely  downwards  and  forwards.     A  good  view  of 
the  whole  bone  may  be  obtained  in  this  way. 

To  obtain  a  reliable  radiograph  of  the  metatarsus  and  phalanges,  the 
foot  is  placed  upon  the  plate  and  the  tube  is  directed  downwards  and  slightly 
towards  the  heel.  The  patient  may  stand  upon  the  plate  ;  or  if  he  is  lying 
on  the  back,  the  knee-joint  is  flexed,  and  the  plantar  aspect  of  the  foot  is 
placed  in  contact  with  the  plate. 


THE  DEVELOPMENT  OF  THE  BONES 

The  importance  of  this  section  is  great,  as  it  is  necessary  to  know  the 
details  of  ossification  and  union  of  these  bones.  The  following  descriptions 
and  drawings  are  based  on  those  from  well-known  works  on  anatomy. 
The  dates  given  are  those  which  have  long  been  recognised  as  the  correct 
ones,  but  it  is  quite  probable  in  the  near  future  that  many  of  those 
quoted  may  have  to  be  revised  as  a  result  of  systematic  investigation  on  bone 
ossification  by  means  of  X-ray  examinations.  It  is  possible  by  this  means 
to  ascertain  accurately  the  normal  dates  of  union,  but  until  the  work  of  X-ray 
examination  has  been  completely  carried  out  it  will  be  necessary  to  use 
the  work  of  the  anatomist. 

The  chief  times  of  union  need  only  be  considered  in  those  bones  which  are 
most  likely  to  be  injured.  The  ends  of  the  long  bones,  the  scapula,  and 
the  pelvis  chiefly  interest  the  radiographer.  The  usefulness  of  a  complete 
though  necessarily  short  description  cannot  be  overestimated.  Diagrams 
and  skiagrams  will  be  used  to  illustrate  changes,  though  it  is  obviously 
impossible  to  include  examples  of  the  epiphyses  at  all  ages.  It  is  hoped  that 
this  section  will  be  found  useful  for  reference,  as  it  is  hardly  possible  for  the 
radiographer  to  carry  all  the  dates  in  his  mind. 

The  Clavicle. — Commencing  with  the  bones  of  the  upper  extremity, 
we  note  that  this  bone  is  developed  from  three  centres,  two  for  the  shaft  and 
one  for  the  sternal  extremity.  The  centre  for  the  shaft  appears  very  early, 
before  any  other  hone ;  according  to  Beclard,  as  early  as  the  thirtieth  day. 
The  centre  for  the  sternal  end  makes  its  appearance  about  the  eighteenth  or 
twentieth  year,  and  unites  with  the  rest  of  the  bone  about  the  twenty-fifth 
year. 

The  Scapula. — Development  takes  place  by  seven  centres:  one  for  the 
body,  two  for  the  coracoid  process,  two  for  the  acromion,  one  for  the  pos- 
terior border,  and  one  for  the  inferior  angle.  Ossification  of  the  body  of  the 
scapula  commences  about  the  second  month  of  foetal  life  by  the  formation  of 
an  irregular  plate  of  bone  immediately  behind  the  glenoid  cavity.  This  plate 
extends  itself  so  as  to  form  the  chief  part  of  the  bone,  the  spine  growing  up 
from  its  posterior  surface  about  the  third  month.  At  birth  the  chief  part  of 
the  scapula  is  osseous,  the  coracoid  and  acromion  processes,  the  posterior 
border  and  inferior  angle  being  cartilaginous.  About  the  first  year  after 
birth  ossification  takes  place  in  the  middle  of  the  coracoid  process,  which 

138 


PLATE  VII. — Normal  Elbow  and  Fractures  in  Region  of  Elbow-joint. 


a,  Normal  elbow-joint,  antero-posterior  loositiou. 

b,  Injury  to  epiphysis  of  olecranon. 

c,  Normal  elbow-joint,  lateral  position. 

d,  Fracture  through  olecranon  process. 


THE  UPPER  EXTREMITY  139 

usually  becomes  joined  with  the  rest  of  the  bone  at  the  time  when  the  other 
centres  make  their  appearance.  Between  the  fifteenth  and  seventeenth 
years  ossification  of  the  remaining  centres  takes  place  in  quick  succession, 
and  in  the  following  order  :  first,  near  the  base  of  the  acromion  and  in  the 
root  of  the  coracoid  process,  the  latter  appearing  in  the  form  of  a  broad  scale  ; 
secondly,  in  the  inferior  angle  and  contiguous  part  of  the  posterior  border  ; 
thirdly,  near  the  extremity  of  the  acromion  ;  and  fourthly,  in  the  posterior 
border.  The  acromion  process,  besides  being  formed  of  two  separate  nuclei, 
has  its  base  formed  by  an  extension  into  it  of  the  centre  of  ossification  which 
belongs  to  the  spine,  the  extent  of  which  varies  in  different  cases.  The 
two  separate  nuclei  unite,  and  then  join  with  the  extension  carried  in  from 
the  spine.  These  various  epiphyses  become  joined  to  the  bone  between  the 
ages  of  twenty-two  and  twenty-five  years.  Sometimes  failure  of  union 
between  the  acromion  process  and  spine  occurs,  the  jmiction  being  formed  by 
fibrous  tissue  or  by  an  imperfect  articulation.  In  some  cases  of  supposed 
fracture  of  the  acromion  with  ligamentous  union  it  is  probable  that  the 
detached  segment  was  never  united  to  the  rest  of  the  bone. 

The  Humerus. — Development  takes  place  by  eight  centres :  one  for 
the  shaft,  one  for  the  head,  one  for  each  tuberosity,  one  for  the  radial  head, 
one  for  the  trochlear  portion  of  the  articular  surface,  and  one  for  each  of  the 
condyles.  The  nucleus  for  the  shaft  appears  near  the  centre  of  the  bone  in 
the  eighth  week,  and  soon  extends  towards  the  extremities.  At  birth  the 
humerus  is  ossified  nearly  in  its  whole  length,  the  extremities  remaining 
cartilaginous.  At  the  beginning  of  the  second  year  ossification  commences  in 
the  head  of  the  bone,  and  during  the  third  year  the  centre  for  the  tuberosities 
makes  its  appearance  usually  by  a  single  ossific  point,  but  sometimes,  accord- 
ing to  Beclard,  by  one  for  each  tuberosity,  that  for  the  lesser  being  small 
and  not  appearing  until  after  the  fourth  year.  By  the  fifth  year  the  centres 
for  the  head  and  tuberosities  have  enlarged,  and  become  joined  so  as  to  form 
a  single  large  epiphysis. 

The  lower  end  of  the  humerus  is  developed  in  the  following  manner  : — ^At 
the  end  of  the  second  year  ossification  commences  in  the  radial  portion  of 
the  articular  surface,  and  from  this  point  extends  inwards,  so  as  to  form  the 
chief  part  of  the  articular  end  of  the  bone,  the  centre  for  the  inner  part  of  the 
articular  surface  not  appearing  until  about  the  age  of  twelve.  Ossification 
commences  in  the  internal  condyle  about  the  fifth  year,  and  in  the  external 
one  not  until  about  the  thirteenth  or  fourteenth  year.  At  about  sixteen  or 
seventeen  years  the  outer  condyle  and  both  portions  of  the  articulating 
surfaces  (having  already  joined)  unite  with  the  shaft.  At  eighteen  years 
the  inner  condyle  becomes  joined,  whilst  the  upper  epiphysis,  although  the 
first  formed,  is  not  united  until  about  the  twentieth  year. 

The  Ulna. — Development  takes  place  by  three  centres :  one  for  the 
shaft,  one  for  the  inferior  extremity,  and  one  for  the  olecranon.  Ossification 
commences  near  the  middle  of  the  shaft  about  the  eighth  week,  and  soon 
extends  through  the  greater  part  of  the  bone.  At  birth  the  ends  are  carti- 
laginous.    About  the  fourth  year  a  separate  osseous  nucleus  appears  in  the 


140  KADIOGEAPHY 

middle  of  the  head,  which  soon  extends  into  the  styloid  process.  At  about 
the  tenth  year  ossific  matter  appears  in  the  olecranon  near  its  extremity, 
the  chief  part  of  this  process  being  formed  from  an  extension  of  the  shaft 
into  it.  At  about  the  sixteenth  year  the  upper  epiphysis  becomes  joined, 
and  at  about  the  twentieth  year  the  lower  one. 

The  Radius. ^ — ^Development  takes  place  by  three  centres,  one  for  the 
shaft  and  one  for  each  extremity.  That  for  the  shaft  makes  its  appearance 
near  the  centre  of  the  bone,  soon  after  the  development  of  the  humerus 
commences.  At  birth  the  shaft  is  ossified,  but  the  ends  of  the  bone  are 
cartilaginous.  About  the  end  of  the  second  year  ossification  commences 
in  the  lower  epiphysis,  and  about  the  fifth  year  in  the  upper  one.  At  the 
age  of  seventeen  or  eighteen  the  upper  epiphysis  becomes  joined  to  the 
shaft,  the  lower  epiphysis  becoming  united  about  the  twentieth  year. 

The  Bones  of  the  Hand. — The  carpal  bones  are  each  developed  by 
a  single  centre.  At  birth  they  are  all  cartilaginous.  Ossification  proceeds 
in  the  following  order :  in  the  os  magnum  and  unciform  an  ossific  point 
appears  during  the  first  year,  the  former  preceding  the  latter  ;  in  the  cunei- 
form, at  the  third  year  ;  in  the  trapezium  and  semilunar,  at  the  fifth  year,  the 
former  preceding  the  latter  ;  in  the  scaphoid,  at  the  sixth  year  ;  in  the 
trapezoid,  during  the  eighth  year ;  and  in  the  pisiform,  about  the  twelfth  year. 

The  metacarpal  bones  are  each  developed  by  two  centres,  one  for  the  shaft 
and  one  for  the  digital  extremity,  for  the  four  inner  metacarpal  bones  ;  one 
for  the  shaft  and  one  for  the  base,  for  the  metacarpal  bone  of  the  thumb, 
which  in  this  respect  resembles  the  phalanges.  Ossification  commences  in 
the  shaft  about  the  eighth  or  ninth  week,  and  gradually  proceeds  to  either 
end  of  the  bone.  About  the  third  year  the  digital  extremities  of  the  four 
inner  metacarpal  bones  and  the  base  of  the  first  metacarpal  bones  commence 
to  ossify,  and  they  unite  about  the  eighteenth  year. 

The  phalanges  are  each  developed  by  two  centres,  one  for  the  shaft  and 
one  for  the  base.  Ossification  commences  in  the  shaft  in  all  three  rows  at 
about  the  eighth  week,  and  gradually  involves  the  whole  of  the  bone  except- 
ing the  upper  extremity.  Ossification  of  the  base  commences  between  the 
third  and  fourth  years,  and  a  year  later  in  those  of  the  second  and  third  rows. 
The  two  centres  become  united  in  each  row  between  the  eighteenth  and 
twentieth  years. 

The  Os  Innominatum  is  a  large,  irregularly  shaped  bone,  which, 
with  that  of  the  opposite  side,  forms  the  sides  and  anterior  walls  of  the 
pelvic  cavity.  In  yomig  subjects  it  consists  of  the  separate  parts  which 
meet  and  form  the  large  cup-shaped  cavity  situated  near  the  middle  of  the 
outer  side  of  the  bone  ;  and  although  in  the  adult  these  have  become  united, 
it  is  usual  to  describe  the  bone  as  divisible  into  three  portions  :  the  ilium, 
the  ischium,  and  the  pubes.  Development  takes  place  by  eight  centres :  three 
primary,  one  for  the  ilium,  one  for  the  ischium,  and  one  for  the  pubes ;  and 
five  secondary,  one  for  the  crest  of  the  ilium,  one  for  the  anterior  inferior 
spinous  process  (said  to  occur  more  frequently  in  the  male  than  in  the  female), 
one  for  the  tuberosity  of  the  ischium,  one  for  the  symphysis  pubis  (more 


PLATE  VIII. — Normal  Knee-joint. 


a,   Normal  knee-joint,  lateral  view. 

h,  Knee-joint  in  young  adult,  irregularity  in  region  of  tubercle  of  tibia. 

c,  Normal  knee-joint,  antero-posterior. 


THE  LOWER  EXTREMITY  141 

frequent  in  the  female  than  in  the  male),  and  one  for  the  Y-shaped  piece  at 
the  bottom  of  the  acetabulum. 

These  various  centres  appear  in  the  following  order  :  (a)  in  the  ilium, 
immediately  above  the  sciatic  notch,  at  about  the  same  period  as  the  develop- 
ment of  the  vertebrae  commences  ;  (b)  in  the  body  of  the  ischium,  at  about  the 
third  month  of  foetal  life ;  and  (c)  in  the  body  of  the  pubes,  between  the  fourth 
and  fifth  months.  At  birth  the  three  primary  centres  are  quite  separate, 
the  crest,  the  bottom  of  the  acetabulum,  and  the  rami  of  the  ischium  and 
pubes  being  still  cartilaginous.  At  about  the  seventh  or  eighth  year  the 
rami  of  the  pubes  and  ischium  are  almost  completely  ossified.  About  the 
thirteenth  or  fourteenth  year  the  three  divisions  of  the  bone  have  extended 
their  growth  into  the  bottom  of  the  acetabulum,  being  separated  from  each 
other  by  the  Y-shaped  portion  of  cartilage,  which  now  presents  traces  of 
ossification.  The  ilium  and  ischium  then  become  joined,  and  lastly  the  pubes, 
through  the  intervention  of  the  Y-shaped  portion.  At  about  the  age  of 
puberty  ossification  takes  place  in  each  of  the  remaining  portions,  and  they 
become  joined  to  the  rest  of  the  bone  about  the  twenty-fifth  year.  It  is 
important  to  bear  in  mind  the  development  of  the  bones  entering  into  the 
hip-joint,  as  this  region  has  to  be  frequently  examined  for  injuries  and 
disease. 

The  FemuF. — The  femur  is  developed  by  five  centres  :  one  for  the  shaft, 
one  for  each  extremity,  and  one  for  each  trochanter.  Of  all  the  long  bones 
except  the  clavicle  it  is  the  first  to  show  ossification  ;  this  commences  in 
the  shaft  about  the  fifth  week  of  foetal  life,  the  centres  of  ossification  appear- 
ing in  the  epiphyses  in  the  following  order  :  first  in  the  lower  end  of  the  bone 
at  the  ninth  month  of  foetal  life — from  this  the  condyles  and  tuberosities  are 
formed  ;  in  the  head  at  the  end  of  the  first  year  of  birth  ;  in  the  great  tro- 
chanter during  the  fourth  year  ;  and  in  the  lesser  trochanter  between  the 
thirteenth  and  fourteenth  years.  The  order  in  which  the  epiphyses  are  joined 
to  the  shaft  is  the  reverse  of  that  of  their  appearance  ;  their  junction  does  not 
commence  until  after  puberty,  the  lesser  trochanter  being  first  joined,  then 
the  greater,  then  the  head,  and  lastly  the  inferior  extremity  (the  first  in  which 
ossification  commenced),  which  is  not  united  until  the  twentieth  year. 

The  Patella. — ^Development  takes  place  by  a  single  centre,  which  makes 
its  appearance  about  the  third  year.  In  two  instances  it  has  been  seen 
cartilaginous  throughout  at  a  much  later  period  (six  years).  More  rarely 
the  bone  is  developed  by  two  centres  placed  side  by  side.  Ossification 
is  completed  about  the  age  of  puberty. 

The  Tibia. — -Development  takes  place  by  three  centres,  one  for  the 
shaft  and  one  for  each  extremity.  Ossification  commences  in  the  centre  of 
the  shaft  about  the  seventh  week,  and  gradually  extends  towards  either 
extremity.  The  centre  for  the  upper  epiphysis  appears  at  birth.  It  is 
flattened  in  form,  and  has  a  thin  tongue-shaped  process  in  front,  which  forms 
the  tubercle.  That  for  the  lower  epiphysis  appears  in  the  second  year.  The 
lower  epiphysis  joins  the  shaft  at  about  the  eighteenth,  and  the  upper  one 
about  the  twentieth  year.     Two  additional  centres  occasionally  exist :   one 


142  RADIOGKAPHY 

for  the  tongue-shaped  process  of  the  upper  epiphysis,  the  tubercle,  and  one 
for  the  inner  malleolus. 

The  Fibula. ^ — Development  takes  place  by  three  centres,  one  for  the 
shaft  and  one  for  each  extremity.  Ossification  commences  in  the  shaft 
about  the  eighth  week  of  foetal  life,  a  little  later  than  in  the  tibia,  and  extends 
gradually  towards  the  extremities.  At  birth  both  ends  are  cartilaginous. 
Ossification  commences  in  the  lower  end  in  the  second  year,  and  in  the  upper 
one  about  the  fourth  year.  The  lower  epiphysis,  the  first  in  which  ossifica- 
tion commences,  becomes  united  to  the  shaft  first,  contrary  to  the  law  which 
appears  to  prevail  with  regard  to  the  junction  of  epiphysis  with  diaphysis. 
This  takes  place  about  the  twentieth  year.  The  upper  epiphysis  is  joined 
about  the  twenty-fifth  year. 

The  Bones  of  the  Foot. — The  tarsal  hones  are  each  developed  by  a 
single  centre,  excepting  the  os  calcis,  which  has  an  epiphysis  for  its  posterior 
extremity,  just  below  the  insertion  of  the  tendo  Achillis.  It  is  seen  as  a  small 
oval  disc.  The  centres  make  their  appearance  in  the  following  order  :  os 
calcis,  at  the  sixth  month  of  foetal  life  ;  astragalus,  about  the  seventh  month  ; 
€uboid,  at  the  ninth  month  ;  external  cuneiform,  during  the  first  year  ; 
internal  cuneiform,  in  the  third  year  ;  middle  cuneiform  and  scaphoid,  in  the 
fourth  year.  The  epiphysis  for  the  posterior  extremity  of  the  os  calcis 
appears  at  the  tenth  year,  and  unites  with  the  rest  of  the  bone  soon  after 
puberty. 

The  metatarsal  hones  are  each  developed  by  two  centres :  one  for  the  shaft 
and  one  for  the  digital  extremity  in  the  four  outer  metatarsals  ;  one  for  the 
shaft  and  one  for  the  base  in  the  metatarsal  bone  of  the  great  toe.  Ossifica- 
tion commences  in  the  centre  of  the  shaft  about  the  ninth  week  and 
extends  towards  either  extremity,  and  in  the  digital  epiphysis  about  the 
third  year  ;  they  become  joined  between  the  eighteenth  and  twentieth  years. 

The  ■phalanges  are  developed  by  two  centres  for  each  bone,  one  for  the 
shaft  and  one  for  the  metatarsal  extremity. 

The  Hyoid  Bone  is  a  bony  arch,  shaped  like  a  horse-shoe,  and  is  of  a 
quadrilateral  form.  Development  takes  place  by  six  centres,  two  for  the 
body  and  one  for  each  cornua.  Ossification  commences  in  the  body  and 
greater  cornua  towards  the  end  of  fcetal  life,  the  centres  for  the  cornua  first 
appearing.  Ossification  at  the  lesser  cornua  commences  some  months 
after  birth. 

The  Sternum  is  a  flat  narrow  bone,  situated  in  the  median  line  in  the 
front  of  the  chest,  and  consisting  in  the  adult  of  three  portions — the  manu- 
brium, the  gladiolus,  and  the  ensiform  or  xiphoid  appendix.  The  sternum, 
including  the  ensiform  appendix,  is  developed  by  six  centres — one  for 
the  first  piece  or  the  manubrium,  four  for  the  second  piece  or  gladiolus, 
and  one  for  the  ensiform  appendix.  Up  to  the  middle  of  foetal  life  the 
sternum  is  entirely  cartilaginous,  and  when  ossification  takes  place  the 
ossific  granules  are  deposited  in  the  middle  of  the  intervals,  between  the 
articular  depressions  for  the  costal  cartilages,  in  the  following  order : 
in  the  first  piece,  between  the  fifth  and  sixth  months ;  in  the  second  and 


THE  TRUNK  143 

third,  between  the  sixth  and  seventh  months ;  in  the  fourth  piece,  at  the 
ninth  month ;  in  the  fifth,  within  the  first  year,  or  between  the  first  and 
second  years  after  birth  ;  and  in  the  ensiform  appendix,  between  the  second 
and  the  seventeenth  and  eighteenth  years  by  a  single  centre,  which  makes 
its  appearance  at  the  upper  part  and  proceeds  gradually  doAvnwards.  To 
these  may  be  added  the  occasional  existence,  as  described  by  Breschet,  of 
two  small  episternal  centres,  which  make  their  appearance,  one  on  each  side 
of  the  sterno-clavicular  notch.  These  are  regarded  by  him  as  the  anterior 
rudiments  of  a  rib,  of  which  the  posterior  rudiment  is  the  anterior  lamina 
of  the  transverse  process  of  the  seventh  cervical  vertebra.  It  occasionally 
happens  that  some  of  the  segments  are  formed  from  more  than  one  centre, 
the  number  and  position  of  which  vary.  Thus  the  first  piece  may  have  two, 
three,  or  even  six  centres.  When  two  are  present,  they  are  generally  situated 
one  above  the  other,  the  upper  one  being  the  larger.  The  second  piece  has 
seldom  more  than  one.  The  third,  fourth,  and  fifth  pieces  are  often  formed 
from  two  centres,  placed  laterally,  the  irregular  union  of  which  will  serve  to 
explain  the  occasional  occurrence  of  the  sternal  foramen  or  of  the  vertical 
fissure  which  occasionally  intersects  this  part  of  the  bone.  Union  of  the 
various  centres  commences  from  below  and  proceeds  upwards,  taking  place 
in  the  following  order  :  the  fifth  piece  is  joined  to  the  fourth  soon  after 
puberty ;  the  fourth  to  the  third  between  the  twentieth  and  twenty-fifth 
years  ;  the  third  to  the  second  between  the  thirty-fifth  and  fortieth  years  ; 
the  second  is  occasionally  joined  to  the  first,  especially  at  an  advanced  age. 

Ossification  of  the  Skull  and  the  Vertebral  Column. — It  is 
unnecessary  to  deal  extensively  with  the  development  of  these  bones.  In 
the  vertebral  column  each  vertebra  is  ossified  from  three  centres,  two  for  the 
vertebral  arch  and  one  for  the  body.  About  the  sixteenth  year  five  secondary 
centres  appear :  one  for  the  extremity  of  each  transverse  process,  one  for 
the  extremity  of  the  spinous  process,  one  for  the  upper  and  one  for  the  lower 
surface  of  the  body.  These  fuse  with  the  rest  of  the  body  about  the  age  of 
twenty -five  years. 

These  are  the  main  points  in  the  ossification  of  the  vertebral  column ; 
but  there  are  exceptions  in  the  case  of  the  first,  second,  and  seventh  cervical, 
and  in  the  lumbar  vertebrae. 

The  atlas  is  usually  ossified  from  three  centres. 

The  axis  is  ossified  from  five  primary  and  two  secondary  centres. 

The  seventh  cervical  varies  in  its  departures  from  the  normal.  A  cervical 
rib  is  due  to  a  persistence  as  a  separate  piece  of  the  costal  part,  which  becomes 
lengthened  laterally  and  forwards. 

The  lumbar  vertebrae  have  each  two  additional  centres  for  the  mammillary 
processes.  The  transverse  process  of  the  first  lumbar  is  sometimes  developed 
as  a  separate  piece,  which  may  remain  permanently  un-united  with  the  rest 
of  the  body,  thus  forming  a  lumbar  rib,  a  peculiarity  rarely  met  with. 


144 


EADIOGEAPHY 


Radiographic  Survey  of  the  Joints  showing  Epiphyses 

The  Ankle-joint. — The  lower  epiphyses  of  the  tibia  and  fibula  are  best 
seen  in  an  antero-posterior  view  of  the  joint.  The  epiphyseal  line  is  nearly 
horizontal  in  the  case  of  both  bones,  but  that  of  the  fibula  is  at  a  lower  level 
and  comes  opposite  the  ankle-joint.  The  internal  malleolus  forms  the  inner 
portion  of  the  lower  tibial  epiphysis,  while  the  external  malleolus  is  practically 


Appears  at^ 
2mJ  year 


Joins  body 
about 
20Vyr 

Appears^ 
at  Z^-^yr. 


lUnites 
about 
IZOthyr 


Fig.  111. — Showing  bones  at  ankle  and  foot  with  epipliyses,  and 
dates  at  which  they  unite  with  the  diaphyses. 


Appears 
at  3 '■-"_>' r 
■Joins  18*-'' 
to20*-^yrs. 


Appears 
ytl'week. 


entirely  composed  of  the  lower  epiphysis  of  the  fibula.     The  latter  epiphysis 
is  greatly  concerned  in  the  increase  in  length  of  the  fibula. 


Table  of  Development  of  the  Taesus 


The  tarsal  bones  develop  by  a  single  centre. 
Os  calcis  .... 


They  appear  approximately  as  follows  : — 
.     Sixth  month  of  foetal  life. 


Sometimes  this  bone  develops  from  two  or  three  centres  of  ossification. 

Astragalus  ....     Seventh  month  of  foetal  life. 

Ninth  month  of  foetal  life. 
First  year. 
Third  year. 


Cuboid 

External  cuneiform 
Internal  cuneiform 
Sliddle  cuneiform 
Scaphoid  . 


Fourth  year. 
Fourth  year. 


The  ossific  centre  for  the  epiphysis  of  the  os  calcis  appears  at  the  ninth  year,  and  may 
sometimes  unite  before  puberty.     It  may  develop  from  two  centres. 


THE  KNEE-JOINT 


U5 


Fig.  112.— Foot. 
Antero-posterior  view,  plantar  aspect  of  foot  on  plate.     Age  14. 

Knee-joint. — The  epiphyses  entering  into  the  formation  of  this  joint  are 
of  the'greatest  importance,  for  it  is  one  of  the  joints  most  frequently  injured. 


Appears  9*^ 
month  of 
foetal   life 


Lower  end  of  femur. 


Upper  end  of  tibia. 


Upper.end  of  fibula. 


Fig.  113. — Diagram  to  show  the  epiphyses  entering  into  the  knee-joint. 

The  epiphysis  of  the  lower  end  of  the  femur  is  the  only  one  in  which  bone 
is  formed  before  birth. 

10 


146  RADIOGRAPHY 

In  an  antero-posterior  view  it  is  seen  as  a  large  irregular  bony  mass, 


Antero-posterior.  Lateral. 

Fig.  114. — Diagrams  to  illustrate  the  appearances  of  the  epiphyses  at  the  knee-joint, 
traced  from  radiographs. 


forming  the  entire  lower  end  of  the  femur. 


Bpiphyspal  line 


i^ss^m/fi^mKm 


I  Patella 


Tubercle 
of  Tibia 


Fig.  115. — Lateral  view  of  knee-joint,  showing  epiphyses. 
Note  prolongation  of  tibial  epiphysis  on  anterior  aspect 
of  tibia.     Age,  14  years. 


The  epiphyseal  line  is  seen  at 
the  level  of  the 
adductor  tubercle 
on  the  inner  side. 
It  is  wavy  in  out- 
line, rises  sharply 
towards  the  centre, 
and  has  a  slightly 
lower  level  at  the 
outer  side  of  the 
bone. 

The  epiphyses 
of  the  tibia  and 
fibula  will  be  seen 
in  the  picture.  The 
epiphyseal  line  of 
the  tibia  resembles 
that  of  the  line  of 
the  lower  end  of 
the  femur.  The 
upper  epiphysis  of 
the  fibula  is  a  small 
mass,  appearing  to 
rest  on  the  top  of 
the  shaft. 


PLATE  IX. — Showing  Epiphyses  of  Hip,  Knee,  and  Ankle  Joints. 

a,   Pelvis  and  hip-joints  in  a  child  of  5-6  years. 

Knee-joint  in  a  child  10-12  years,     b,   Lateral  view,     c,  Antero-posterior  view. 

Ankle-joint  in  a  child  10-12  years,     d,  Lateral  aspect,      e,  Antero-posterior  aspect. 


THE  KNEE-JOINT  147 

In  a  lateral  view  the  epiphyseal  lines  of  the  femur  aad  fibula  are  nearly 


Lines  of 
Iracture 


Head  of 
Fibula 


Fig. 


116. — Antero-posterior  view  of  knee-joint  showing 
epiphyses.     Plate  on  posterior  aspect  of  joint. 


Fig.  117. — Fracture  of  tibia  and 
fibula.  Practically  no  displace- 
ment. The  appearances  of  the 
epiphyses  at  both  ends  of  the 
bones  indicate  the  age  of  the 
patient  to  be  about  3  years. 
The  fibula  has  a  convexity  to- 
wards the  tibia. 


horizontal.  The  epiphysis  of  the  upper  end  of  the  tibia  is  seen  to  have  a 
tongue  -  like  projec- 
tion extending  down 
the  front  of  the  bone 
to  the  tubercle  of 
the  tibia.  In  some 
instances  this  projec- 
tion does  not  reach 
so  far  as  the  tubercle, 
and  the  latter  is 
seen  arising  from  a 
separate  centre  of 
ossification.  It  is  fre- 
quently the  seat  of  in- 
jury and  inflammation 
(see  Plates  VIII.  Fig. 
h,  and  XVIII.  Fig.  a). 

The    Hip -joint,  pjq 
— The    epiphysis    of 
the  upper  end  of  the 
femur  includes  merely 
the  articular  head  of 


Symphy,,. 


118. — Diagram  to  show  the   epiphyses 
and  bones  entering  into  the  hip-joint. 


148  KADIOGRAPHY 

the  bone  and  forms  no  part  of  the  neck.  In  an  X-ray  picture  it 
resembles  somewhat  the  appearance  of  the  epiphysis  of  the  upper  end  of 
the  humerus.  The  greater  and  lesser  trochanters  arise  from  separate  centres 
of  ossification,  but  these  are  less  frequently  seen  in  radiographs  than  is  the 
larger  epiphysis  (see  Plate  IX.  a). 


Upper  end  of 
shaft  of  femur 


Epiphyses  for 
head  have  not 
yet  appeared 


Epiphysis  for 
lower  end  of 
femur 


Fig.  119. — Pelvis  and  femora  of  a  child  two  days  old,  showing  ossification  of  bones  of  pelvis, 
hip  and  knee  j  oints.     Note  lower  epiphyses  of  femur  present  at  birth. 

The  Wrist-joint. — -The  epiphysis  of  the  lower  end  of  the  radius  is 
seen  in  an  antero-posterior  view  of  the  joint  as  a  wedge-shaped  shadow,  and 
is  thicker  on  the  outer  than  on  the  inner  side  of  the  wrist.  The  epiphyseal 
line,  though  irregular  and  wavy,  is  never  rough  and  jagged  as  in  a 
fracture.  This  epiphysis  has  a  great  share  in  the  increase  in  length  of  the 
shaft. 

The  epiphysis  of  the  lower  end  of  the  ulna  is  seen  at  a  higher  level  than 
that  of  the  radius  and  shows  the  prominence  of  the  styloid  process  on  its 
inner  side. 

The  centres  of  ossification  for  the  carpal  bones  show  according  to  the 
age  at  which  the  joint  is  examined  (see  "  Ossification  "). 


THE  WRIST-JOINT 


149 


Table  of  Ossification  for  Carpal  Bones 


The  carpus  is  entirely  cartilaginous  at  birth, 
at  the  following  times  : 


Centres  appear  for  these  carpal  bones 


Os  magnum 
Unciform 
Cuneiform 
Semilunar 


first  year, 
second  year, 
third  year, 
fifth  year. 


Trapezium 
Scaphoid 
Trapezoid 
Pisiform 


fifth  year, 
seventh  year, 
eighth  year, 
twelfth  year. 


The  "  OS  central,"  lying  between  the  bones  of  the  first  and  second  rows,  is  present  in 
man  as  a  small  cartilage  situated  between  the  "  trapezoid,"  trapezium,  os  magnum, 
and  "  scaphoid,"  at  the  second  month,  and  disappears  about  the  fourth  month  of 
foetal  hfe.     In  rare  cases  it  persists  as  a  separate  bone  in  the  adult. 


^         '  Appears  3':?^r. 


Appears  3-4'-''yr 
Urates  l8-20«^>r 


^ 


lj£;^Appe3re  4.-5'-"yr. 
■     es  IS-ZO'Iyr. 


IS-ZO'^'^r 
('Appeal 


Fig.  120. — Diagram  showing  ossification 
of  the  bones  of  the  hand  and  the 
wrist-joint  witli  the  times  of  union  of 
epiphyses  with  diaphyses. 


Fig.  121. — Hand  of  a  child  over  five  years  old. 
Shows  development  of  bones  of  lower  ends  of 
radius  and  ulna,  carpal  bonts,  metacarpals,  and 
phalanges.  The  epiphysis  for  lower  end  of  radius 
well  developed.  The  ulnar  epiphysis  has  not  yet 
appeared.  The  os  magnum  and  unciform,  semi- 
lunar and  cuneiform  bones  are  also  shown.  The 
pisiform  is  not  shown.  Note  also  the  centre  for 
the  proximal  end  of  the  metacarpal  bone  of  the 
thumb. 


The  epiphyses  of  the  four  inner  metacarpal  bones  are  seen  at  the  distal 
ends  of  the  shafts,  but  in  the  phalanges  and  in  the  metacarpal  bone  of  the 
thumb  the  epiphyses  are  found  at  the  proximal  ends  of  the  respective 
bones. 


150 


EADIOGRAPHY 


Fig.  122. — Shows  stage  of  ossification  in  a  young 
adult  under  twenty  years. 

The  Elbow-joint. — The  lower  epiphysis  of  the  humerus  at  the  age  of 
five  or  six  years  merely  shows  the  centre  for  the  capitulum  as  a  small  round 
mass.     In  an  antero-posterior  picture  of  the  joint  it  is  seen  as  a  wedge- 


FlG.  123. — Diagram  showing  epi-  ■-"        ------ 

physes  of  the  bones  forming  the      Fig.  124. — Elbow-joint,  antero-posterior  view,  shows  epiphyses, 
elbow-joint.  Age  14. 

shaped  mass,  its  lower  surface  being  convex,  and  lying  below  the  external 
condyle.      At  twelve  the  centres  for  the  trochlea  and  the  external  epicon- 


THE  ELBOW  AND  SHOULDER  JOINTS 


151 


Olecranon 


Shaft  of 
Ulna 


Fig.  ]25. — Lateral  view  of  elbow-joint, 
to  show  epiphyses.     Age  14. 


dyle  have  appeared,  and  have  united   with   the  centre  for  the  capitulum, 

forming  the  lower  epiphysis.     The  lower  end  of  the  humerus  Ls  one  of  the 

bones  most  frequently  involved  in  injuries   and  disease,   but  the   other 

bones    entering   into    the    joint   should   also  be    remembered  in  relation 

to   the    times    at   which 

their  epiphyses  join  the 

diaphyses.    The  internal 

epicondyle  is  not  a  part 

of    the  lower    epiphysis 

of  the  humerus,  but  is 

formed  from  a  separate 

centre     of     ossification. 

In  an  X-ray  picture  it  is 

seen    as   a    small,    oval 

mass,  higher  up  on  the 

inner  side  of  the  humerus, 

and  intimately  connected 

with  the  internal  condyle. 

The    epiphysis    of    the 

head   of   the    radius    is 

seen  as  a  small  disc,  just 

above  the  upper  end  of 

the  bone.     In  a  lateral 

view  of  the  joint  at  about  five  years  the  lower  epiphysis  of  the  humerus 

appears  to  be  semilunar  in  shape,  fitting  closely  to  the  lower  end  of  the 

shaft.     At  a  later  age  the  parts  become  accentuated,  and  great  care  must 

be  exercised  in  dis- 
tinguishing the  normal 
appearances  when  ex- 
amining the  joint  for 
suspected  injuries.  A 
normal  radiograph 
should  always  be  com- 
pared with  the  sus- 
pected one  if  mistakes 
are  to  be  avoided. 

The  Shoulder  - 
joint. — The  upper  epi- 
physis of  the  humerus 
is  found  as  a  dome- 
shaped  mass,  which 
appears  to  rest  on  the 
top  of  the  shaft.  It 
is  composed  of  the 
,     ,  centres   for  the   head 

Fig.  126. — Diagram  to  show  bones  entering  into  the  shoulder-  i  <■         i  n 

joint.     The  clavicle  has  not  been  included.  and  for  the  greater  and 


Humerus 


Head  of 

Radius 


.^2  for  coracoid 
process. 


Epiphyses  of  head  /  <'>y 
Situbercles  blend 
at  Sthyr  and  unite 
with  bodyat20l')yf 


152  KADIOGKAPHY 

lesser  tuberosities,  which  unite  to  form  the  epiphysis.  The  epiphyseal  line 
lies  a  little  way  above  the  surgical  neck,  and  is  not  horizontal,  but  is  higher 
in  the  middle  of  the  shaft  than  at  the  outer  and  inner  sides.     The  increase 


Fig.  127. — Normal  shoulder-joint  showing  condition  of  epiphyses 
at  the  head  of  humerus. 

in  length  of  the  humerus  takes  place  principally  at  this  epiphysis,  and 

hence  its  great  importance. 

Certain  anatomical  facts  are  worthy  of  note  when  we  are  considering 

inflammatory  conditions  and 
injuries  of  the  bones  iti  the 
neighbourhood  of  joints,  more 
especially  in  children  and 
young  adults.  It  is  important 
to  keep  in  mind  the  chief 
centres  of  ossification  and  the 
periods  at  which  the  epiphyses 
join  the  diaphyses  in  the  joints 
most  liable  to  injury  ;  but  as 
it  is  obvious  that  one  cannot 
readily  recall  the  whole  of 
them  it  is  hoped  that  a  refer- 
ence to  the  foregoing  pages 
j^^j^, ,    \  .  /  ,     .'"     .  ,       ,  ,.  will  be  helpful.     The  marked 

Fig.  128. — Shoulder-joint,  .showing  epiphyseal  line.  _  ^ 

Centres  for  head  and  great  tuberosity  have  joined.  There  differences  between  the  appcar- 
is  evidence  of  a  partial  fracture  at  the  surgical  neck.  ^^^^^  ^^    .^.^^^    -^  ^^^j^  ^^^^-^ 

and  in  adult  life  must  be  noted  to  avoid  errors  in  diagnosis.  Fractures 
are  relatively  more  frequent  in  adults,  while  greenstick  fracture  and 
separation  of  epiphyses  are  more  prevalent  in  injuries  occurring  before  the 
epiphyses  have  joined  up  with  the  diaphyses. 


SESAMOID   BONES  153 

The  after  history  of  an  injury  is  greatly  influenced  in  its  results  when  the 
injury  occurs  in  the  neighbourhood  of  the  epiphyseal  line.  Arrested  develop- 
ment is  a  frequent  result  of  such  an  injury.  There  are,  therefore,  certain 
points  which  should  be  remembered  in  relation  to  the  principal  joints  of  the 
body  which  will  be  briefly  mentioned,  reference  to  figures  illustrating  these 
points  being  made  as  occasion  arises. 

Sesamoid  Bones. — These  are  small  rounded  masses,  cartilaginous  in 
early  life,  osseous  in  the  adult,  which  are  developed  in  tendons  which 
exert  a  great  amount  of  pressure  upon  those  parts  over  which  they  glide. 
It  is  said  that  they  are  more  commonly  found  in  the  male  than  in  the 
female,  and  in  persons  of  an  active  muscular  habit  than  in  those  who 
are  weak  and  debilitated.     They  have  a  free  articular  facet. 

The  sesamoid  bones  of  the  joints  in  the  lower  extremity  are  :  the 
patella,  in  the  tendon  of  the  quadriceps  extensor  ;  two  small  sesamoid  bones 
in  the  tendon  of  the  flexor  brevis  pollicis,  opposite  the  metatarso-phalangeal 
joint  of  the  great  toe  ;  and  occasionally  one  at  the  metatarso-phalangeal 
joint  of  the  second  toe,  of  the  little  toe,  and,  still  more  rarely,  of  the  third  and 
fourth  toes.     In  the  knee-joint  posteriorly  there  may  also  be  one. 

In  the  upper  extremity  they  are  found  on  the  palmar  aspect  of  the 
metacarpo- phalangeal  joint  in  the  thumb,  developed  in  the  tendon  of  the 
flexor  brevis  pollicis,  occasionally  one  or  two  opposite  the  metacarpo- 
phalangeal articulations  of  the  fore  and  little  fingers,  and  still  more  rarely 
one  opposite  the  corresponding  joints  of  the  third  and  fourth  fingers. 

Those  found  in  the  tendons,  which  glide  over  certain  bones,  occupy  the 
following  positions:  one  in  the  tendon  of  the  peroneus  longus,  where  it 
glides  through  the  groove  in  the  cuboid  bone ;  one  which  appears  later  in 
the  tendon  of  the  tibiahs  anticus,  opposite  the  smooth  facet  on  the  internal 
cuneiform  bone  ;  one  is  found  in  the  tendon  of  the  tibialis  posticus,  opposite 
the  inner  side  of  the  astragalus  ;  one  in  the  outer  head  of  the  gastroc- 
nemius behind  the  outer  condyle  of  the  femur,  and  one  in  the  psoas 
and  iliacus,  where  they  glide  over  the  body  of  the  pubes. 

Sesamoid  bones  are  found  occasionally  in  the  tendon  of  the  biceps, 
opposite  the  tuberosity  of  the  radius  ;  in  the  tendon  of  the  glutseus  maximus, 
as  it  passes  over  the  great  trochanter,  and  in  the  tendons  which  wind  round 
the  inner  and  outer  malleoli. 


INJURIES  OF  BONES  AND  JOINTS 

The  methods  which  are  employed  for  the  determination  of  injuries  of 
bones  and  joints  are  (1)  fluoroscopy,  (2)  radiography.  Both  should  be 
employed,  the  former  for  the  determination  of  the  presence  of  an  injury 
and  for  the  purpose  of  centering  the  tube  under  the  injured  part.  In  regard 
to  diagnosis  by  screening  only  a  few  words  of  caution  are  necessary.  While 
in  a  number  of  gross  lesions  with  a  degree  of  displacement  and  dislocations 
it  is  possible  to  make  a  positive  diagnosis  at  once,  it  must  be  pointed  out 
that  a  negative  diagnosis  of  injury  to  bone  should  never  be  made  on  the 
screen  examination  alone.  A  plate  should  always  be  exposed  after  the 
screen  examination  has  been  made  if  the  operator  has  not  been  able  to 
detect  an  injury.  If  this  procedure  is  followed  it  is  possible  to  avoid  making 
many  serious  errors  in  diagnosis.  Fractures  of  the  phalanges  when  there  is 
no  displacement  are  frequently  unrecognisable  under  the  screen.  Crushing 
of  the  bones  in  the  neighbourhood  of  a  joint,  sprain,  fractures,  and  many  so- 
called  trivial  injuries  to  bones  and  joints  will  be  overlooked  if  the  radio- 
graphic method  is  not  employed. 

The  examination  of  the  bones  and  joints  in  the  normal  individual  is 
comparatively  easy,  in  the  injured  patient  it  is  often  a  matter  of  extreme 
diflS.culty  to  adjust  the  tube  and  plate.  Great  ingenuity  may  have  to  be 
displayed  in  certain  cases.  The  best  method  to  employ  is  to  place  the  patient 
upon  a  radiographic  couch.  It  is  convenient  to  have  a  good  supply  of 
cushions,  air-bags,  and  sand-bags  in  order  to  get  a  position  of  comparative 
ease  for  the  patient.  Many  patients  complain  of  the  hardness  of  the  X-ray 
couch. 

The  tube  should  be  accurately  centred  in  the  tube-box,  and  its  focus 
point  should  be  capable  of  ready  adjustment  by  movements  in  two  directions 
under  the  couch.  With  a  plumb  line  it  is  possible  to  quickly  centre  the  tube 
under  the  central  point  of  a  joint  or  bone. 

Injuries  of  the  Skull  and  Spine 

The  skull  is  frequently  examined  for  evidence  of  fracture.  Fractures 
may  occur  at  the  base,  when  they  can  be  recognised  by  departures  from  the 
normal  on  a  lateral  or  antero-posterior  radiograph.  Both  positions  should 
be  taken.  In  children,  when  the  sutures  are  very  evident,  care  must  be 
exercised  to  distinguish  between  these  and  a  fracture.  In  the  region  of  the 
temporal  bone  this  is  most  important. 

154 


FRACTURES  OF  THE  SKULL 


155 


Fracture  of  the  Vault  of  the  Skull.— A  depressed  fracture  can 
readily  be  detected  when  a  lateral  view  of  the  skull  ls  taken.  The  extent  of 
the  injury  and  the 
degree  of  depression 
should  be  noted. 

Fracture  at  the 
base  of  the  skull  is 
difficult  to  determine. 
It  may  occur  at  any 
part  of  the  base  and 
may  be  represented 
as  a  fine  fissure  in  the 
bone.  When  this 
occurs  in  the  neigh- 
bourhood of  the 
sutures  it  is  often 
impossible  to  make  a 
positive  statement  as 
to  the  nature  of  an 
injury.  In  children 
where  the  sutures  have 
not  closed  it  is  still 


Fig.  129. — (Jommiuutbd  fracture  of  augle  of  lower  jaw. 
This  skiagrani  shows  the  teeth,  particularly  the  roots  in  the  lower 


jaw.     The  inferior  dental  canal  is  seen  running  along  the  jaw. 
tooth  shows  extensive  caries. 


One 


more  difficult.     In  doubtful  cases  stereoscopic  radio- 


FiG.  130. — Fracture  through  ramus  of  lower  jaw.     The  soft  parts  show  well. 


graphs  should   be   taken.      CHnical  signs   should   always    be  taken   into 
account. 


156 


EADIOaRAPHY 


Fractures  in  the  Orbital  Region  are  very  difficult  to  distinguish. 
Fine  detail  must  be  obtained,  and  care  should  be  exercised  to  obtain  radio- 
graphs which  show  no  evidence  of  movement  on  the  part  of  the  patient. 
This  is  often  a  matter  of  difficulty,  because  patients  suffering  from  injury  to 
the  skull  and  brain  are  not  likely  to  keep  the  head  steady  long  enough 
to  allow  of  a  sufficient  exposure;  hence  in  these  cases  very  rapid  expo- 
sures are  indicated,  and  intensifying  screens  should  be  used  to  cut 
down  the  exposure  to  the  minimum.  The  orbital  margins  should  be 
carefully  examined  to  detect  slight  departures  from  the  normal,  which 
may  be  the  only  evidence  of  fracture. 

The    Zygfomatic     Arch     is     occasionally     broken.      There    may   be 

a  depression  of  the  bone, 
this  being  readily  de- 
tected when  an  antero- 
posterior radiograph  is 
obtained. 

Fracture  of  the 
Superior  Maxilla. — 
This  may  occur  in  head 
injuries,  or  a  tooth  may 
be  driven  into  the  an- 
trum of  Highmore. 
The  palatine  arch  may 
be  disturbed.  Careful 
examination  of  the 
radiograph  is  necessary 
when  injuries  in  this 
region  are  suspected. 

Fracture  of  the 
Inferior  Maxilla  (Man- 
dible).—This  bone  is 
frequently  injured.  Three  positions  are  available:  (1)  antero-posterior ;  (2) 
lateral ;  (3)  film  in  the  mouth.  The  condyle  may  be  injured  when  the  bone 
is  subjected  to  direct  violence.  The  coronoid  process  may  be  fractured 
either  by  direct  or  indirect  violence. 

It  is  somewhat  difficult  to  get  a  goodradiographof  one  side  of  the  lower  jaw, 
because  of  the  superimposing  of  the  shadows.  Probably  the  best  method  to  em- 
ploy is  to  centre  the  tube  behind  and  a  little  below  the  angle  of  the  jaw.  With 
the  plate  on  the  injured  side,  the  tube  is  centred  over  a  spot  behind  and  below 
the  angle  of  the  uninjured  jaw,  thus  avoiding  the  overlapping  of  the  latter. 
By  using  the  above  method  it  is  possible  to  obtain  a  picture  of  the  side 
required,  showing  the  whole  of  the  lower  jaw  in  profile,  the  temporo-maxillary 
articulation  being  well  shown.  This  is  also  a  useful  method  when  it  is  neces- 
sary to  examine  the  jaw  for  tumour  or  dental  disease. 

Fractures  of  the  Nasal  Bones. — These  are  occasionally  fractured  on 
one  or  both  sides.     A  plate  on  the  injured  side  is  generally  sufficient  to  show 


Fig.  131. — Fracture  dislocation  of  cervical  vertebrae. 


PLATE  X. — Fractures  in  Region  of  the  Shoulder-joint. 

a,  Fracture  through  great  tuberosity. 
h,  Exostosis  of  angle  of  scapula. 

c,  Fracture  (stellate)  of  body  of  scapula  ;  the  detail  has  been  lost  in  reproduction. 

d.  Fracture  at  upper  end  of  shaft  of  humerus,  there  is  no  displacement.     Note  the  epiphyseal  line  of  head 
of  humerus. 


FRACTURES  OF  THE  VERTEBRAE 


157 


the  injury.  An  antero-posterior  view  is  also  useful.  Stereoscopic  pictures 
may  be  necessary.  A  small  piece  of  X-ray  film  placed  in  contact  with  the 
side  of  the  nose  will  give  a  sharp  picture. 

Injuries  of  the  Cervical  Vertebrae. — Two  positions  have  already 
been  described.  The  lateral  is  the  most  useful,  for  it  shows  readily  very 
slight  departures  from  the  normal. 

Fracture  dislocation  of  the  cervical  vertebrae  is  a  not  uncommon  in- 
jury. Any  part  of  the  cervical  region  may  be  the  seat  of  a  dislocation. 
The  appearances  are  unmistakable  when  well  marked,  but  the  doubt- 
ful cases  give  rise  to 
considerable  difficulty  in 
diagnosis.  Fig.  131 
illustrates  a  partial  frac- 
ture dislocation  of  the 
upper  cervical  vertebrae, 
which  was  not  definitely 
diagnosed  for  several 
weeks  after  the  injury 
occurred. 

Injuries  of  the 
Dorsal  Vertebrae. — 
The  dorsal  spine  may  be 
involved  in  injuries  of 
the  thorax.  Ribs  may 
be  fractured  and  the  ver- 
tebral column  crushed, 
or  partial  dislocation 
may  be  present.  Two 
positions  are  useful :  (1) 
a  postero-anterior,  that 
is,  the  plate  on  the  back 
and  the  tube  in  front ; 
(2)  a  lateral,  to  show 
the  bodies  of  the  verte- 
brae. It  is  often  ex- 
tremely difficult  to  show  fractures  of  the  posterior  parts  of  the  spinal  column. 
Crushing  and  displacement  of  the  bodies  may  be  clearly  indicated.  Fracture 
of  the  transverse  process  sometimes  occurs.  When  there  is  considerable 
displacement  it  is  possible  to  demonstrate  the  position  of  the  lesion. 


Fig.  132.- 


Fractures  of  vertebral  border  of  scapula  and  three  ribs 
(gunshot  wound). 


Fracture  of  the  Ribs 

The  demonstration  of  fracture  of  the  ribs  is  often  a  matter  of  great 
difiiculty.  This  is  particularly  so  when  the  bone  is  broken  through  and  no 
displacement  takes  place.  When  there  is  considerable  displacement  the 
fracture  shows  up  readily.     The  best  positions  for  showing  fractures  of  these 


158  KADIOGRAPHY 

bones  are  antero-posterior  and  lateral.     The  latter  is  often  a  difficult  position 
in  which  to  show  a  fracture,  especially  in  stout  patients. 

Fracture  of  the  Clavicle 

(1)  At  the  acromial  end  external  to  the  trapezoid  ligament,  usually  pro- 
duced by  direct  violence.  The  inner  fragment  retains  its  position  unaltered, 
but  the  outer  fragment  is  dragged  down  by  the  weight  of  the  arm,  and  for- 
wards by  the  action  of  the  muscles,  so  that  it  lies  at  right  angles  to  the  rest 
of  the  bones. 

(2)  Between  the  coraco-clavicular  ligaments.  There  is  little  displace- 
ment.    It  may  be  shown  radiographically  as  a  fissured  fracture  of  the  bone. 

(3)  Through  the  greater  convexity  of  the  bone.  There  is  frequently 
considerable  displacement.     (See  Plate  XL  Fig.  d.) 

(4)  At  the  sternal  end.  This  may  be  complicated  by  a  partial  dis- 
placement. 

(5)  Greenstick  fracture  of  the  clavicle,  a  common  injury  in  children. 
Frequently  only  a  decided  bend  on  the  bone  is  seen,  but  occasionally  a 
minute  crack  may  be  detected. 

Fracture  of  the  Scapula 

The  Body  of  the  scapula  may  be  broken  in  cases  of  injury  due  to  direct 
violence,  the  fracture  being  usually  of  the  fissured  or  stellate  variety  when 
the  flat  surface  of  the  bone  is  damaged.  The  vertebral  border  is  occasionally 
involved  in  these  injuries. 

The  Spine  of  the  scapula  may  also  be  fractured,  generally  as  the  result 
of  direct  violence. 

The  Acromion  Process  may  be  broken  by  direct  violence  applied  to 
the  point  of  the  shoulder.  The  arm  hangs  powerless  by  the  side,  and  the 
shoulder  is  flattened.  The  irregularity  of  the  bone  can  be  readily  detected. 
and  crepitus  can  be  elicited  by  raising  the  elbow  and  rotating  the  arm. 
Occasionally  merely  the  tip  is  detached,  and  then  the  above  signs  will 
not  be  present. 

The  Coracoid  Process  is  rarely  fractured,  and  only  from  direct  violence. 
There  is  but  little  displacement,  on  account  of  the  many  powerful  ligaments 
attached  to  it.  In  spite  of  the  attachment  of  such  powerful  muscles 
as  the  pectoralis  minor,  biceps,  and  coraco-brachialis,  the  displacement  is 
not  great,  as  the  process  is  kept' in  position  by  the  coraco-clavicular  ligament. 

The  Neck  of  the  scapula  may  be  fractured  immediately  behind  the 
glenoid  cavity,  but  this  is  a  rare  injury.  Its  existence  has  been  doubted. 
Astley  Cooper  and  South  have  stated  that  cases  so  described  are  in  reality 
fractures  of  the  upper  end  of  the  humerus.  There  is,  according  to  South, 
no  specimen  in  any  of  the  London  museums  illustrating  fracture  of  the  neck 
of  the  scapula  (Erichsen).  Walsham  describes  one  case  of  this  variety  of 
fracture  which  is  in  Guy's  Hospital  museum,  and  Rose  and  Carless  figure  an 
instance  of  this  variety.     It  is  usually  due  to  direct  violence ;  a  portion  of  the 


PLATE  XL — Fractures  in  Kegion  of  Shoulder-joint. 

a,  Fracture  at  upper  end  of  humerus,  a  longitudinal  splitting  of  the  shaft  with  head  displaced 
forwards  and  downwards  (dislocation  of  the  head). 

h,  Separation  of  the  great  tuberosity  of  the  humerus. 

c,  Fracture  through  lower  aspect  of  glenoid  cavity. 

d,  Fracture  of  the  clavicle  (nnddle  third),  the  base  of  the  acromion  process  is  irregular  and  appears 
to  be  fractured. 


FRACTURES  OF  THE  SCAPULA  AND  HUMERUS  159 

articular  surface  is  broken  off  and  displaced  downwards.  Plate  XI.  Fig.  c 
illustrates  a  case  of  this  rare  variety  of  fracture  through  the  lower  segment  of 
the  glenoid  cavity,  with  displacement  downwards  of  the  fragment.  The 
patient  was  admitted  to  the  Great  Northern  Central  Hospital  suffering  from 
an  injury  to  the  shoulder,  which  was  taken  to  be  a  dislocation  of  the  head 
downwards.  The  skiagram  shows  the  fracture  and  the  typical  displacement. 
A  case  recorded  by  Spence  is  the  first  authentic  instance  of  this  fracture. 
A  patient  who  had  fallen  upon  the  shoulder  whiLst  in  a  state  of  intoxication 
was  brought  into  the  Edinburgh  Royal  Infirmary.  The  man  died  some  days 
afterwards  from  meningitis.  "  The  fracture  was  found  to  pass  obliquely 
from  below  upwards  and  forwards,  commencing  about  half  an  inch  behind  the 
origin  of  the  long  head  of  the  triceps,  and  separating  the  neck  and  four-fifths 
of  the  lower  part  of  the  glenoid  cavity  from  the  scapula.  The  long  head  of 
the  triceps  and  the  whole  of  the  glenoid  ligament  had  also  been  torn  from  the 
upper  fragment  of  the  glenoid  cavity,  and  carried  along  with  the  displaced 
portion."  In  fractures  through  the  neck  of  the  scapula,  the  coracoid  process 
would  necessarily  follow  the  glenoid  cavity,  being  detached  along  with  it. 
Mobility  of  the  coracoid  would,  therefore,  be  a  valuable  sign  of  this  rare 
fracture. 

Fractures  of  the  Humerus 

The  fractures  to  which  this  bone  is  liable  may  be  conveniently  divided 
into  three  groups  : 

(1)  Those  afiecting  the  upper  extremity,  or  that  part  which  is  situated 
above  the  surgical  neck. 

(2)  Those  of  the  shaft,  and 

(3)  Those  of  the  lower  articular 
extremity. 

Fractures  at  the  Upper  End  of  the 
Humerus. — (a)  Of  the  anatomical  neck, 
the  so-called  intracapsular  fracture.    This 


Fig.     134. — Fracture     of    lower    end    of 
Fig.  133. — Fracture  of  shaft  of  humerus  humerus,  with  backward  displacement 

and  upper  end  of  radius  (shrapnel  wound).  of  the  lower  fragment. 


160 


EADIOGKAPHY 


Fig. 


135. — Fracture  of  .shaft  of  humerus 
lower  fragment  and  elbow-joint. 


rotation  of 


Fig.  136. — Fracture  through  external  condyle  with  for- 
ward and  upward  displacement  of  the  fragment  of 
bone.  The  presence  of  chronic  arthritic  changes  in 
the  joint  indicates  that  the  injury  is  one  of  some 
standing.  The  radiograjih  was  taken  many  months 
after  the  primary  injury. 


is  always  due  to  blows  upon 
the  shoulder,  never  to  direct 
violence.  It  is  evidenced  by 
signs  of  a  severe  local  trauma, 
with  loss  of  mobility  of  the 
arm.  The  head  of  the  humerus 
is  found  to  be  irregular  in  shape 
on  examination  from  the  axilla, 
and  the  fragment,  if  detached, 
may  be  felt.  Crepitus  is  ob- 
tained on  moving  the  arm,  and 
therefis  slight  shortening. 

(6)  Fracture  through  the 
surgical  neck.  This  is  a  common 
injury.  There  may  or  may  not 
be  a  considerable  degree  of 
displacement,  or  the  lower 
point  of  the  bone  may  be  im- 
pacted into  the  upper ;  the 
latter  may  be  partially  split. 

(c)  The  great  tuberosity  of 
the  humerus  is  frequently  de- 
tached and  displaced. 

{d)  The  epiphysis  of  the 
head  may  be  detached  from  the 
shaft,  and  there  may  be  a 
considerable  degree  of  displace- 
ment. 

Fracture  of  the  Shaft 
of  the  Humerus.— This  bone 
is  frequently  fractured,  and 
the  injury  may  occur  at  any 
part  of  its  length.  The  most 
common  injury  is  about  the 
junction  of  the  upper  with  the 
middle  third.  The  displace- 
ment may  be  considerable. 
An  unusual  displacement  is 
shown  in  Fig.  135,  a  trans- 
verse fracture  with  marked 
rotation  of  the  elbow -joint 
inwards  ;  the  lower  fragment 
of  the  humerus  is  nearly  at 
right  angles  to  the  upper. 
The  head  of  the  radius  appears 
to  have  been  injured. 


PLATE  XII. — Fractures  in  Region  of  Elbow-joint. 


a,  Vertical  fracture  of  head  of  radius. 

b,  Fracture  through  head  of  radius,  displacement  forwards  of  fragment. 

c,  Fracture  through  lower  end  of  humerus  above  epiphyseal  line,  displacement  backwards. 

d,  Fracture  dislocation  at  elbow-joint. 


INJURIES  IN  REGION  OF  ELBOW-JOINT 


101 


Injuries  in  the  Region  of  the  Elbow-joint 

Fracture  of  the  Lower  End  of  the  Humerus.— The  humerus  is 
frequently  involved  in  injuries  of  the  elbow-joint  in  adults  and  in  children. 
It  gives  rise  to  a  typical  displacement,  which  is  clearly  revealed  upon 
examination  of  the  radiographs  obtained.  The  displacement  varies  with 
the  direction  of  the  injury.  The  lower  end,  along  with  the  elbow-joint, 
may  be  displaced  backwards,  while  there  may  also  be  some  lateral  displace- 
ment and  rotation.  Stereoscopic  radiographs  are  extremely  useful  in  these 
cases. 


Fig.  138. — Fractures  through  shafts 
of  radius  and  ulna.  The  position 
of  both  iDones  is  faulty.  There  is 
also  a  fracture  through  the  lower 
end  of  the  radius. 


Fig.  137. — Dislocation  of  elbow-joint. 

Separation  of  the  Epiphysis  of  the 

lower  end  of  the  humerus  is  a  common 
injury  in  this  region.  It  is  very  difl&cult  to 
show  in  children,  and  requires  more  careful 
examination  than  any  other  injury. 

Dislocations  of  the  Elbow-joint  are 
common,  and  frequently  combined  with 
fracture  in  the  region. 

Fracture  of  the  Olecranon  may  be  complete  or  incomplete.  It  is 
commonly  a  transverse  fracture,  though  it  may  be  oblique  or  vertical,  or  the 
upper  portion  may  be  shattered.  The  displacement  varies  with  the  extent 
of  the  fracture. 

Fracture  of  the  Coronoid  is  a  rare  injury.  It  is  generally  associated 
with  a  dislocation  of  the  forearm  backwards.  When  the  fracture  is  reduced, 
the  bones  tend  to  slip  out  again  readily. 

Fracture  of  the  Head  of  the  Radius  is  by  no  means  an  uncommon 
injury  ;  it  may  be  complete  or  incomplete. 

11 


162  EADIOGRAPHY 

Fracture  of  the  Shaft  of  the  Radius  and  Ulna 

One  or  other  of  the  bones  may  be  broken.     The  usual  seat  of  injury  is 
near  the  middle  of  the  shaft,  in  which  case  both  bones  are  frequently  broken, 


Autero-posterior.  Lateral. 

Fig.  139. — Fracture  of  shaft  of  ulna  (the  result  of  a  gunshot  wound). 

and  the  displacement  may  be  considerable.     One  or  other  bone  may  be 
involved  in  injuries  at  the  elbow- joint  or  wrist- joint. 

Injuries  at  the  Wrist-joint 

Fracture  of  the  lower  end  of  the  radius  and  ulna  is  included  in  the 
description  of  the  common  Colles  fracture.  The  results  of  the  analysis  of  a 
large  number  of  cases  of  fracture  at  the  wrist- joint  investigated  by  Dr. 
R.  W.  A.  Salmond  and  the  author  may  be  quoted  {Lancet,  Nov.  2,  1912). 

(a)  The  Radius. — This  shows  injury  in  93  per  cent,  of  the  total  number  of 
cases.  The  large  percentage  is  without  doubt  due  to  the  important  part  the 
lower  end  of  this  bone  takes  in  the  mechanism  of  the  wrist-joint.  Most  injuries 
at  the  wrist  are  carried  up  from  the  hand  and  are  transmitted  through  the  radius^ 
hence  the  great  frequency  of  damage  to  the  lower  end  of  the  bone.  The  radius 
alone  is  injured  in  41  per  cent,  of  the  total  number  of  cases^  showing  that,  while 


PLATE  XIII. — Fractures  in  Forearm,  Wrist,  and  Hand. 

a,  Fracture  of  terminal  phalanx  of  tliunib,  backward  displacement.     Lateral  and  antero -posterior  views. 

b,  Fracture  of  trapezium. 

c,  Fracture  through  lower  end  of  shaft  of  radius,  very  little  displacement. 

d,  Non-union  fracture  of  radius  and  ulna,  formation  of  false  joints. 


PLATE  XIV. — Fractdres  at  Wrist-joint. 

Fracture  of  lower  end  of  radius,  a,  Lateral  view  showing  displacement,  b,  Antero-posterior  view 
showing  nature  of  fracture. 

c,  Antero-posterior  view  of  separated  epiphysis  of  lower  end  of  radius,  d,  Lateral  view  to  show 
displacement. 

e.   Fracture  through  lower  end  of  radius.     /,  Colles  fracture,  antero-posterior  view. 


INJURIES  AT  THE  WRLST- JOINT  103 

it  is  injured  in  nearly  every  case'/ the  injury  is  more  often  distributed  to  some  of 
the  other  bones  than  confined  to  itself. 

The  radius  is  injured  along  with  the  styloid  process  of  tlie  ulna  in  12  per 
cent,  of  the  total  number  of  cases. 

The  radius  is  damaged,  together  with  the  shaft  and  the  styloid  of  the  ulna, 
in  3  per  cent,  of  cases.  This  is  therefore  infrequent,  and  the  more  so  as  the 
majority  of  the  instances  are  due  to  a  fracture  carried  up  from  the  damaged 
styloid  process  into  the  shaft  of  the  ulna.  The  frequency  of  injuries  to  the  radius 
and  the  shaft  of  the  ulna  is  also  low — namely,  3  per  cent.  It  will  be  noticed  how 
much  more  frequently  the  radius  is  injured  with  the  styloid  of  the  ulna  than  with 
the  shaft,  and  it  is  interesting  to  compare  this  with  the  corresponding  injury  in 
the  un-united  epiphyses  series.  Injury  is  confined  to  the  radius  and  carpus  in 
4  per  cent,  of  cases. 

Direction  of  Injury. — The  great  majority  are  transverse,  67  per  cent. ;  T- 
shaped  in  16  per  cent. ;  fracture  from  the  centre  of  the  lower  end  across  the  styloid 
process,  8  per  cent. ;  V-shaped,  4  per  cent.  ;  fracture  of  styloid  process,  3  per 
cent.  ;  oblique,  2  per  cent.  ;  longitudinal,  2  per  cent.  ;  and  injury  at  the  inferior 
radio-ulnar  articulation,  about  1  per  cent.  Where  the  shafts  of  both  fore- 
arm bones  are  injured  the  direction  in  the  radius  is  transverse  in  all  the  cases 
examined. 

Position  of  Injury. — -By  far  the  commonest  is  half  an  inch  above  the  lower 
end  of  the  bone.  It  is  striking  that  99  per  cent,  of  the  injuries  recorded  are  three- 
quarters  of  an  inch  or  less  from  the  lower  end. 

Displacement  of  Fragment. — This  is  backward  in  74  per  cent.,  forward  in 
2  per  cent.,  and  there  is  none  in  24  per  cent.,  but  most  of  the  cases  examined 
had  been  manipulated  by  the  surgeon,  so  displacement  is  more  or  less  mislead- 
ing. Outward  and  inward  rotation  and  displacements  are  not  recorded,  as 
many  of  the  cases  showed  rotation,  chiefly  outwards,  but  it  was  often  difficult 
to  decide  which  to  include  and  which  not. 

(6)  The  Ulna. — Some  part  of  this  is  injured  in  49  per  cent,  of  the  total  number 
of  cases,  about  one-half  the  frequency  of  the  radius.  Injury  to  the  styloid  process 
occurs  in  46  per  cent,  of  the  total  number  of  cases,  so  that  by  far  the  commonest 
injury  to  this  bone  in  this  series  is  here.  It  is  interesting  to  contrast  the  frequen- 
cies with  which  the  styloid  processes  of  the  ulna  and  radius  are  damaged.  In  the 
former  46  per  cent,  and  in  the  latter  3  per  cent,  show  fracture  of  these  processes, 
and  we  think  the  explanation  is  due  partly  to  the  styloid  of  the  radius  being 
structurally  stronger  than  that  of  the  ulna,  partly  because,  the  fragment  of  the 
radius  being  most  commonly  displaced  backwards  and  rotated  outwards,  the 
internal  lateral  ligament  attached  to  the  apex  of  the  ulnar  styloid  is  put  on  the 
stretch,  and  must  either  rupture  or  exert  tension  on  that  process,  while  at  the 
same  time,  with  the  fragment  of  the  radius  rotated  outwards,  the  interarticular 
fibro-cartilage  attached  to  the  base  of  the  ulnar  styloid  pulls  on  that  base  and 
helps  to  damage  it. 

Direction  of  Injury. — There  is  no  tendency  towards  any  one  type,  nor  is 
there  any  predominant  type  in  this  bone  when  the  shafts  of  both  forearm  bones 
are  damaged.  That  no  tendency  has  been  noted  is  perhaps  because  the  injury 
is  relatively  rare  and  a  sufficient  number  of  cases  has  not  been  examined. 

Position  of  Injury. — All  are  within  2  inches  of  the  lower  end,  and  so,  on  the 
whole,  extend  further  up  the  shaft  than  in  the  radius.  As  would  be  expected, 
the  majority  are  at  the  styloid  process,  94  per  cent. 

Displacement  of  Fragment  of  the  Shaft. — This  is  chiefly  backwards,  as  in  the 
radius,  though,  owing  to  a  fracture  in  some  cases  being  continued  up  from  the 
styloid  process,  the  frequency  with  no  displacement  is  also  high. 


164  RADIOGEAPHY 

(c)  The  Carpal  Bones. — Injury  is  present  in  one  or  more  of  these  in  13  per 
cent,  of  the  total  number  of  cases.  This  proves  how  frequently  these  are  damaged 
in  wrist  injuries,  and  probably  the  frequency  is  even  greater,  as  only  undoubted 
cases  of  injury  are  included.  The  carpus  without  either  of  the  forearm  bones  is 
injured  in  5  per  cent,  of  cases,  the  carpus  and  radius  in  4  per  cent.,  and  in  none  is 
the  carpus  injured  with  the  ulna  only,  showing  that  the  ulna  does  not  directly 
take  part  in  the  mechanism  of  the  wrist-joint.  The  carpus,  radius,  and  ulna  are 
together  injured  in  3  per  cent,  of  cases.  The  scaphoid  is  the  one  most  frequently 
damaged,  no  less  than  thirteen  times  out  of  nineteen.  Next  in  order  is  the 
trapezium,  while  the  carpal  bones  towards  the  ulnar  side  are  less  frequently 
involved. 

Fractures  of  the  Bones  of  the  Hand 

Fractupe  of  the  Carpal  Bones.— Any  of  these  may  be  fractured, 
examples  being  met  with  in  routine  examination. 

Fractures  of  the  Metacarpal  Bones  are  common.  Perhaps  the  most 
frequently  met  with  is  that  of  the  base  of  the  first  metacarpal,  Bennet's 
fracture.  Plate  XV.,  fig.  d  illustrates  the  nature  of  the  fracture  and  the 
displacement  commonly  met  with. 

Fractures  of  the  Phalangres  are  also  common.  There  may  be  no 
displacement  in  some  fractures.  The  diagnosis  can  be  made  by  a  screen 
examination,  but  even  with  these  small  bones  it  is  always  well  to  confirm 
the  diagnosis  by  taking  a  radiograph.  A  negative  diagnosis  should  never 
be  made  on  the  screen  examination  alone. 


Fractures  of  the  Pelvis 

The  pelvis  is  often  injured  by  direct  or  indirect  violence.  A  radiograph 
should  be  taken  of  the  whole  pelvis  in  one  picture,  or  several  smaller  ones 
may  be  taken  to  discover  the  nature  of  the  injury. 

The  iliac  bones  may  be  fractured,  when  it  is  sometimes  difficult  to  show 
the  seat  of  the  lesion.  When  the  sacrum  is  damaged,  there  may  be  a  fracture 
at  the  sacro-iliac  synchondrosis,  and  the  body  of  the  sacrum  may  also  be 
involved  in  these  injuries.  The  pelvis  is  often  damaged  when  the  violence  is 
of  a  crushing  type,  or  it  may  be  broken  by  direct  violence.  The  ischium 
may  also  participate  in  the  injury.     The  coccyx  is  frequently  fractured. 

In  all  doubtful  cases  both  sides  of  the  pelvis  should  be  examined,  and 
the  hip-joints  should  also  receive  attention.  The  common  injuries  are  easily 
distinguished,  but  there  are  many  grades  of  fracture,  where  the  injury  may 
not  be  demonstrable  if  only  one  radiograph  be  taken. 

Injuries  near  the  Hip-joint 

In  some  cases  of  injury  at  the  hip-joint  a  widening  of  the  interarticular 
space  may  indicate  an  effusion  of  blood  into  the  joint,  which  later  on  may 
lead  to  inflammatory  changes  and  abscess  formation. 


Q  2 


^is 


FRACTURES  OF  THE  FEMUR 


165 


An  uncommon  injury  to  the  hip-joint  has  been  recorded,  where  the  head 
of  the  bone  was  driven  through  the  acetabulum  into  the  pelvic  cavity.  Or 
the  acetabulum  may  be  fractured  to  a  lesser  degree.  This  may  be  shown 
on  examination. 

The  Neck  of  the  Femur  is  frequently  broken  when,  especially  in  old 
people,  there  may  be  impaction.  Traumatic  coxa  vara  is  a  fairly  common 
occurrence. 

Fracture  through  the  Great  Trochanter  is  also  common.  It  may 
be  localised  to  the  trochanter  or  may  extend  downwards  obliquely  into  the 
shaft. 


Fractures  of  the  Femur 

Fracture  throug'h  the  Shaft  below  the  lesser  trochanter  is  an  injury 
often  met  with. 

Fractures  of  the  Lower  End. 

—  (1)  Transverse  supra  -  condyloid 
fracture  is  practically  identical  with 
that  involving  the  lower  third  of  the 
femur. 

(2)  T-  or  Y-shaped  fracture  of  the 
condyles.  In  this  a  transverse  frac- 
ture is  complicated  by  a  fissure 
which  runs  into  the  joint,  separating 
the  two  condyles. 

(3)  Separatio?i  of  either  condyle 
always  results  from  direct  violence, 
the  line  of  fracture  being  oblique. 

(4)  The  lower  epiphysis  of  the 
femur  is  separated  from  the  shaft  in 
young  people. 

(5)  Longitudinal  and  spiral  frac- 
tures running  down  to  the  knee- 
joint  are  met  with  in  the  femur. 


Fig.  140. — Fracture  through  shafts  of  both  femora. 
The  fracture  is  comminuted  ou  the  left  side. 


Fractures  of  the  Patella 

These  may  vary  from  mere  fissures  to  complete  fracture  with  wide 
separation  at  the  line  of  fracture.  The  partial  fracture  is  the  one  which  it  is 
most  important  to  recognise.  A  lateral  view  of  the  knee-joint  is  the  most 
useful  position  in  which  to  radiograph  the  joint  for  its  recognition. 


Fractures  of  the  Bones  of  the  Leg 

The  tibia  and  fibula  may  be  involved  when  there  is  a  fracture  of  the 
lower  end  of  the  femur ;   they  may  be  broken  together  or  either  bone  by 


166 


KADIOGRAPHY 


itself.  Fractures  of  the  shaft  of  the  tibia  and  fibula  may  vary  from  a  fine 
crack  to  a  marked  degree  of  fracture,  with  displacement  of  the  fragments. 
The  tibia  is  frequently  the  seat  of  a  spiral  fracture.  The  fibula  only  may  be 
fractured,  when  there  is  no  marked  displacement  or  external  sign  of  fracture. 


Fractures  in  the  Neighbourhood  of  the  Ankle-joint 

These  are  usually  produced  by  indirect  violence.     There  may  be  marked 

displacement  of  the  foot. 

Pott's  Fracture. — The  fibula  is  generally  broken,  three  inches  above 

the  tip  of  the  external 
malleolus,  and  the  foot  is 
displaced  outwards.  The 
internal  malleolus  may 
also  be  broken,  with  frac- 
ture of  the  lower  end  of 
the  fibula,  or  it  alone 
may  be  broken. 

Fracture  of  the  Os 
Calcis  is  a  comparatively 
common  injury,  the  re- 
sult of  direct  violence. 
The  degree  of  damage  to 
the  bone  varies  from  a 
crack  to  a  severe  crushing 
of  the  bone. 

Fracture  of  the 
Astragalus. — The  lesion 
is  often  a  severe, '  com- 
minuted one .  Both  bones 
may  be  broken  when  a 
patient  lands  heavily  on 
both     feet ;     and     these 

fractures  are  often  associated  with  fracture  of  other  bones  of  the  foot.     Any 

of  the  tarsal  bones  may  be  fractured.      The  extent  of  the  injury  is  often 

difficult  to  determine.     It  may  be  merely  a  crushing  of  the  bone,  in  which 

case  it  is  not  easy  to  distinguish  the  injury  from  changes  which  are  the  result 

of  disease,  or  there  may  be  a  distinct  line  of  separation. 

The  metatarsal  bones  are  frequently  involved  in  injuries  to  the  foot. 

Fractures  may  be  transverse  or  longitudinal.     Fissured  fracture  of  the  bone 

is  not  uncommon. 

The  phalanges  are  also  frequently  injured.      Two  positions  of  the  foot 

should  always  be  taken  when  looking  for  fractures.      Stereoscopic  pictures 

are  very  helpful  in  doubtful  cases. 


Fig.  141. — Fracture  of  os  calcis  (gunshot  wound). 


iL. 


PLATE  XVI.— NoiiMAi.  Hji',  Dislocation,  and  Fracture  at  Hip-joint. 

a,  Normal  liip-joint,  showing  the  head  of  the  femur  ;  the  acetabulum  is  seen  surrounding  part  of  the  head. 

h,  Dislocation  at  hip-joint, 
c,  Fracture  through  neck  of  femur  (intracapsular). 


PLATE  XVIf. — Injuries  and  Disease  of  Pelvis  and  Hip-joint. 


a,  Fracture  of  pelvis  in  a  child  ;  the  injury  has  occurred  at  both  pubic  bones,  and  on  one  side 
through  the  ischium. 

b,  Fracture  of  neck  of  femur,  impaction  into  great  trochanter. 

c,  Displacement  of  upper  end  of  femur  in  a  child.  The  acetabulum  is  eroded  and  the  head  of  femur 
is  absent.  This  is  probably  the  result  of  tuberculosis.  The  appearances  are  similar  to  those  of  con- 
genital dislocation. 


DISEASES  OF  BONE 

All  varieties  of  bone  disease  are  met  with  in  the  radiographic  examination 
of  the  bones,  it  being  possible  to  trace  the  progress  of  disease  from  the  slightest 
beginnings  to  the  most  advanced  stages.  A  thorough  appreciation  of  the 
normal  appearance  of  bone  is  necessary  before  we  can  make  out  departures 
from  it.  Good  negatives  are  essential,  that  is,  the  negative  must  show  the 
finer  detail  as  well  as  the  outline  of  the  bone.  Soft  tubes  give  better  plates 
for  this  purpose  than  hard  ones,  but  the  exposures  require  to  be  longer, 
and  this  is  in  some  cases  a  disadvantage,  as  movement  on  the  part  of 
the  patient  is  apt  to  spoil  the  picture.  When  a  long  exposure  is  necessary 
the  limb  may  be  kept  quite  still  by  laying  sand-bags  around  it  and  upon  the 
parts  not  required  in  the  picture,  or  soft  pads  may  be  placed  on  the  limb, 
and  a  compression  apparatus  fixed  lightly  down  upon  them.  The  use  of  a 
cylindrical  diaphragm  seems  to  give  sharper  radiographs  by  cutting  off  the 
secondary  radiations.  When  practicable  it  is  better  to  place  the  X-ray  tube 
as  far  away  from  the  plate  as  possible,  a  distance  of  three  feet  (or  more) 
giving  the  parts  with  less  distortion.  When  a  particular  bone  has  to  be 
examined  it  is  a  good  plan  to  get  the  corresponding  one  on  the  healthy  side  for 
comparison,  taking  care  that  both  bones  are  radiographed  under  the  same 
conditions  of  tube  and  distance. 

A  brief  consideration  of  the  pathology  of  bone  is  necessary  in  order  to 
understand  clearly  the  various  conditions  met  with  in  the  course  of  examina- 
tion of  bone  disease.  Many  different  terms  are  applied  more  or  less  loosely 
to  the  pathological  processes,  and  much  confusion  is  introduced  thereby. 

Necrosis. — Necrosis  or  death  of  bone  may  occur  in  a  variety  of  forms, 
and  from  many  different  causes  : 

(1)  Acute  localised  suppurative  periostitis,  the  sequestrum  or  dead  mass 
being  then  simply  a  superficial  plate  or  flake  of  the  compact  interior. 

(2)  Acute  infective  osteomyelitis,  the  sequestrum  then  often  involving 
the  whole  thickness  of  the  bone,  and  invading  more  or  less  of  the  diaphysis. 

(3)  Acute  septic  osteomyelitis,  usually  traumatic  in  origin,  the  seques- 
trum being  annular  in  shape,  and  involving  more  of  the  interior  of  the  bone 
than  the  exterior. 

(4)  Acute  or  subacute  septic  osteitis  of  cancellous  bone,  the  sequestrum 
consisting  of  small  spiculated  fragments  of  the  bony  cancelli  which  have 
escaped  absorption  by  the  granulation  tissue  which  always  forms  in  such  a 
process. 

167 


168  EADIOGEAPHY 

(5)  Tuberculous  disease  of  cancellous  tissue,  the  sequestrum  being 
light  and  porous,  often  infiltrated  with  curdy  material,  and  rarely  separated 
completely  from  the  surrounding  parts. 

(6)  Syphilitic  disease  of  cancellous  or  compact  bone,  usually  resulting 
from  excessive  sclerosis,  or  gummatous  disease  of  the  periosteum,  which 
has  become  septic. 

(7)  The  action  of  local  irritants,  e.g.  mercury  and  phosphorus. 
Caries. — (1)  Osteoporosis,  or  rarefaction  of  bone,  a  clinical  condition 

resulting  from  inflammation,  and  consisting  of  a  soft  and  spongy  condition 
of  the  bone. 

(2)  Caries  sicca,  when  the  process  occurs  without  suppuration. 

(3)  Caries  suppurativa,  when  pus  is  always  present. 

(4)  Caries  fungosa,  when  granulation  tissue  is  always  in  excess,  especi- 
ally in  tuberculous  disease  of  the  articular  ends  of  bones. 

(5)  Caries  necrotica. — Necrosis  is  associated  with  caries,  the  sequestra 
consisting  of  spiculated  fragments,  or  in  tuberculous  disease  of  larger  masses. 

Sclerosis  of  Bone  is  usually  the  result  of  some  chronic  inflammatory 
infection  : 

(a)  Chronic  periostitis,  whether  simple  or  syphilitic. 

(6)  Chronic  osteomyelitis,  simple,  tuberculous,  or  syphilitic. 

(c)  Chronic  osteitis  of  the  compact  bone,  which  is  always  secondary  to 
a  case  of  the  former. 

Classification  of  Inflammatory  Affections  of  Bone 

(1)  Periostitis. — (a)  Acute  localised,  with  or  without  suppuration. 
(6)  Acute  diffuse,  always  associated  with,  or  secondary  to,  acute  in- 
fective osteomyelitis. 

(c)  Chronic  simple,  or  hyperplastic. 
{d)  Chronic  tuberculous, 
(e)  Chronic  syphilitic. 

(2)  Osteitis  of  Compact  Bone,  which  is  always  associated  with,  and 
secondary  to,  either  periostitis  or  osteomyelitis,  and  so  will  not  be  described 
separately.  The  acute  form  results  in  necrosis,  the  subacute  in  osteoporosis, 
and  the  chronic  in  sclerosis,  except  in  tuberculous  disease. 

(3)  Osteomyelitis,  or  inflammation  of  the  medulla  of  long  bones, 
(a)  Acute  septic  (traumatic). 

(6)  Acute  infective  (idiopathic),  acute  panostitis. 

(c)  Subacute  simple  or  infective,  e.g.  after  fractures,  or  during  the 
separation  of  sequestra,  resulting  primarily  in  rarefaction,  but  finally  in 
sclerosis. 

{d)  Chronic  simple,  tuberculous  or  syphilitic,  usually  causing  general 
enlargement  and  sclerosis  of  the  bone,  even  if  locally  some  rarefaction  is 
present. 

(4)  Osteitis  of  the  Cancellous  Tissue  may  similarly  be : 
(a)  Acute  septic,  or  traumatic. 


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PLATE  XX.— Fractures  at  the  Ankle-joint. 


a.   Oblique  fracture  through  lower  end  of  fibula,      (a)   Lateral,      {b)  Antero-posterior  views. 

b,  Fracture  of  internal  and  external  malleoli,  displacement  of  foot  outwards  at  ankle-joint. 

c,  Fracture  of  astragalus.  d,  Fracture  dislocation  at  ankle-joint. 

e.  Fracture  lower  end  of  fibula. 


PLA.TE  XXI.  —  Fractokes  of  Leg,  Ankle,  and  Foot. 

«,   Oblique  fracture  of  shaft  of  tibia,   lateral  view,  shows  epiphj'ses   of  lower  end  of  tibia  and   also  of 
OS  calcis. 

b,  Antero-posterior  view  of  tibia  and   fibula,   showing  an  oblique  fracture  of  shaft  of  tibia  ;    and  also 
epiphyses  at  lower  end  of  tibia  and  fibula. 

c,  Fracture  through  shaft  of  femur  ;  the  bone  is  rai'efied  and  is  probably  the  seat  of  secondary  carcinoma. 

d,  Fracture  of  lower  end  of  tibia  and  fibula,  forward  dislocation  of  tibia. 

e,  Fractures  of  tibia  and  fibula. 

/;   Fractui'e  of  base  of  second  and  third  metatarsal  bone. 


DISEASES  OF  BONE  169 

(6)  Acute  infective. 

(c)  Subacute  simple  or  septic. 

(d)  Chronic  simple,  syphilitic,  or  tuberculous. 

When  limited  to  the  articular  end  of  a  bone  in  a  young  person,  this  is 
sometimes  termed  epiphysitis. 

Acute  Localised  Periostitis  is  usually  the  result  of  traumatism.  It 
may  end  in  an  inflammatory  swelling  of  the  surface  of  the  bone,  which  later 
may  cause  a  superficial  abscess.  A  thickening  of  the  soft  parts  over  the  bone 
may  be  shown.  Resolution  may  follow  this,  and  a  localised  thickening  at 
the  seat  of  inflammation  may  remain  for  some  time.  If  suppuration  occurs 
and  pus  forms,  it  maybe  possible  to  demonstrate  its  presence  radiographically. 

Superficial  Necrosis. — This  is  characterised  by  the  separation  of  small 
particles  of  dead  bone.  New  bone  may  be  thrown  out  around  the  inflamed 
area,  and  leave  evidence  in  the  form  of  layers  of  more  or  less  dense  bone. 

Acute  Infective  Osteomyelitis. — Acute  necrosis  occurs  generally  in 
children  of  low  vitality,  often  of  tubercular  inheritance.  The  early  manifesta- 
tions of  this  disease  are  often  extremely  slight.  A  hardly  perceptible  in- 
flammatory process  in  the  neighbourhood  of  the  epiphyseal  line  or  near  a 
joint  rapidly  spreads,  involving  the  whole  diaphysis  of  the  bone.  A  sub- 
periosteal abscess  may  form,  while  the  central  portion  of  the  bone  escapes 
almost  entirely.  Should  the  process  commence  in  the  vicinity  of  the  epi- 
physeal line  it  may  spread  in  several  directions,  may  involve  the  medullary 
cavity,  and  give  rise  to  the  most  typical  form  of  osteomyelitis.  Necrosis 
follows,  usually  implicating  the  whole  thickness  of  the  medullary  cavity  and 
diaphysis,  and  sometimes  extending  its  whole  length.  Occasionally  the 
neighbouring  joint  becomes  involved.  The  pictures  presented  by  this  disease 
show  all  stages,  from  a  preliminary  inflammatory  process,  to  advanced 
necrosis,  formation  of  sequestra,  and  new  bone  formation.  If  radiographs 
are  taken  at  regular  intervals,  the  whole  process  of  inflammation,  suppuration, 
necrosis  of  bone,  sequestra  formation,  deposit  of  new  bone  around  the  dead 
bone,  and  the  gradual  building  up  of  new  bone  after  operation  to  remove 
the  sequestra  may  be  followed  up. 

The  pathology  of  this  form  of  disease  of  bone  may  be  watched  by  means 
of  radiography.  The  demonstration  of  the  presence  of  free  bone  in  a  cavity 
surrounded  by  new  bone  is  a  guide  to  the  surgeon  in  the  operation  as  to  when 
and  where  to  operate,  and  indicates  clearly  the  progress  the  bone  is  making 
in  the  direction  of  recovery. 

Acute  Septic  Osteomyelitis. — This  arises  as  a  result  of  infection  from 
without,  in  cases  of  compound  fracture,  and  after  amputation  or  excision  of 
bone  ;  the  shafts  of  long  bones  are  affected,  and  the  disease  generally  runs  a 
rapid  course. 

Typhoid  Osteitis. — The  typhoid  bacillus  may  lie  dormant  for  years 
without  causing  any  abscess  formation.  The  appearance  is  typical,  and 
is  shown  in  Fig.  142. 

Chronic  Inflammation  of  Bone.  —  Chronic  osteo  -  periostitis,  a 
chronic  inflammatory  process,  results  in  overgrowth,  thickening,  and  con- 


170 


RADIOGRAPHY 


densation,  (1)  as  a  localised  chronic  periostitis,  traumatic,  rheumatic,  or 
syphilitic  in  origin  ;  or  (2)  as  a  diffuse  form,  usually  tubercular  or  syphilitic, 
which  tends  to  involve  the  whole  bone.  It  may  result  in  a  small  abscess  or 
central  necrosis.  Around  this  focus  the  bone  becomes  thick  and  indented. 
Examples  of  this  are  shown  in  Plate  XXII.,  figs,  d  and  e. 


Fro.  142.  —  Typhoid  osteitis  and  periostitis  resulting  in  an 
abscess. 


Fig.  143. — Elbow-joint  showing 
disease.  Formation  of  new 
bone  along  shaft  of  iilna  and 
humerus.  Chronic  osteitis  and 
periostitis,  probably  tuber- 
culous iu  origin. 


Tuberculous  Disease  of  Bone. — This  form  of  disease  of  bone  is 
frequently  met  with  in  X-ray  examinations.  Bones  may  be  affected  in  two 
ways  by  tuberculosis.  The  periosteum  or  the  cancellous  tissue  may  be 
primarily  involved. 

Tuberculous  Periostitis,  or  specific  inflammation  of  the  periosteum,,  is 
met  with.  Caseation  and  suppuration  are  likely  to  follow,  frequently  leading 
to  the  formation  of  abscesses,  and,  later,  of  discharging  sinuses.  The 
inflammation  may  result  in  a  thickening  of  the  layers  of  bone  and  a  shutting 
in  of  the  products  of  suppuration,  hence,  if  situated  near  a  joint,  the  pus 
may  burrow  under  the  dense  bone  and  invade  the  joint. 

Tuberculous  Osteitis  always  arises  in  cancellous  tissue,  and  it  affects  the 
short  bones  or  the  shafts  or  ends  of  the  long  bones.  The  short  bones  of 
the  hands  and  feet  are  liable  to  this  condition,  especially  in  children.  When 
the  phalanges  are  involved  the  condition  is  known  as  tuberculous  dactylitis. 
The  typical  appearance  of  this  condition  is  shown  in  Plate  XXVII.,  fig.  c. 
Several  bones  may  be  simultaneously  affected.  Some  slight  injury  may 
determine  the  onset  of  tuberculous  periostitis  or  osteitis. 

Tuberculous  Epiphysitis. — An  inflammation  affecting  primarily  the 
epiphyseal  line  and  adjacent  bone.  The  tendency  is  for  it  to  spread  and 
involve  the  joints  by  the  invasion  of  the  synovial  membranes.  Separation  of 
the  epiphysis  may  result.    The  adjacent  bones  show  a  condition  of  osteitis  and 


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SYPHILITIC  DISEASES  OF  BONE  171 

periostitis.  Abscess  of  bone,  more  common  in  adults  than  in  cliildren,  may- 
result.  Chronic  abscess  in  the  head  of  the  tibia  is  somewhat  frequent.  The 
characteristic  symptom  of  deep  aching  pain  calls  attention  to  the  possibility 
of  bone  abscess.  The  bone  around  the  abscess  cavity  is  frequently  very 
dense,  though  it  varies  in  this  respect  in  parts  of  its  circumference.  Radio- 
graphically,  the  condition  may  be  recognised  by  an  increase  in  shading  and 
loss  of  detail  in  the  bone  structure  on  the  surface.  The  periosteal  outline 
is  blurred,  and  may  show  patches  of  caries  or  collections  of  pus.  The  soft 
parts  are  frequently  involved  in  the  inflammatory  process,  and  a  soft  puffy 
swelling  may  be  seen  over  the  affected  portion  of  bone.  When  the  disease 
has  advanced,  the  original  focus  of  disease  shows  up  as  a  lighter  area,  with 
patches  of  rarefaction  of  bone  leading  from  it.  The  fine  detail  of  the  bone 
is  lost,  and  a  general  haziness  is  left  in  its  place.  Later,  when  pus  has  formed, 
an  irregular  abscess  cavity  can  be  seen,  there  being  as  a  rule  very  little  con- 
densation of  bone  round  the  abscess.  Should  the  cancellous  tissue  in  the 
neighbourhood  of  an  epiphyseal  line  be  involved,  the  disease  extends  through 
the  line,  and  affects  the  epiphysis,  which  shows  as  a  spongy  rarefaction  with 
irregular  edges.  The  inflammatory  process  spreads  into  the  joint  itself,  and 
sets  up  a  synovitis,  which  is  characterised  by  a  general  distension  of  the  joint 
and  an  obscuring  of  detail. 

Syphilitic  Diseases  of  Bone. — The  osseous  tissue  may  be  involved  in 
acquired  syphilis  in  either  the  secondary  or  tertiary  form.  Syphilis  of  the 
bone  is  frequently  met  with,  and  it  is  often  difficult  to  differentiate  it  from 
a  simple  inflammatory  process.  Chronic  thickenings  in  the  form  of  nodes  are 
diagnostic  of  syphilis.  When  a  considerable  extent  of  bone  is  involved,  it 
may  be  difficult  to  distinguish  between  this  condition  and  an  early  stage  of 
malignant  disease.  In  the  latter  the  disease  spreads  more  rapidly,  and  the 
characteristic  appearances  of  malignancy  manifest  themselves.  In  the 
tertiary  period  the  bones  may  participate  in  the  changes  which  involve  any 
and  every  tissue  of  the  body.  These  consist  of  an  infiltration  and  overgrowth 
of  the  connective  tissue,  which,  if  diffused  through  the  organs,  produce  scler- 
osis, or,  if  localised  to  one  spot,  lead  to  the  formation  of  a  gumma.  The 
subperiosteal  gumma  may  be  met  with.  It  probably  results  from  caries  of  the 
adjacent  bone,  and  if  it  extends  widely  an  extensive  area  of  bone  may  become 
eroded  and  irregular.  The  skull  is  the  part  most  frequently  involved  in  these 
changes,  and  may  show  a  curious  worm-eaten  appearance.  The  formation  of 
gummata,  several  of  which  may  break  down,  gives  a  curiously  uneven  appear- 
ance to  the  radiograph  of  the  skull,  thickening  and  enlargement,  alternating 
with  broken-down  tissue,  leading  to  marked  thinning  of  the  bone  in  places. 

Congenital  Syphilis. — Nodes,  known  as  Parrot's  nodes,  form  on  or 
around  the  anterior  fontanelle.  The  newly  formed  bony  tissue  becomes 
sclerosed  and  dense,  and  deformity  may  then  persist  through  life.  A 
similar  condition  is  met  with  in  the  shafts  of  the  long  bones,  due  to  the 
alternating  deposition  of  lamellae  of  soft  and  hard  bone  outside  the  ordinary 
compact  bone. 

Syphilitic  Epiphysitis. — This  condition  is  characterised  by  enlargement 


172  EADIOGEAPHY 

of  the  ends  of  the  bones.  It  is  met  with  in  infants,  and  somewhat  resembles 
rickets,  but  comes  on  at  an  earlier  date.  The  enlargement  is  situated  mainly 
in  the  epiphyses,  but  not  uncommonly  extends  some  way  along  the  shaft, 
thus  contrasting  forcibly  with  rickets.  The  change  commences  at  the  zone 
of  calcified  cartilage  nearest  the  diaphysis,  which  becomes  friable,  thick,  and 
irregular,  and  may  become  transformed  into  granulation  tissue  as  the  disease 
progresses.  Later,  reparation  of  the  epiphysis  may  follow.  The  disease  is 
usually  symmetrical  and  often  multiple.  A  symmetrical  overgrowth  of  the 
tibia,  combined  with  an  anterior  curvature,  often  occurs  in  syphilitic  children, 
resulting  in  permanent  deformity  of  the  legs. 

Craniotahes. — A  condition  characterised  by  localised  absorption  of  the 
osseous  tissue  of  the  cranium,  leaving  small  areas  where  the  bone  is  thinned 
or  absent.     Radiographically,  these  are  often  met  with. 

Rickets. — The  chief  changes  are  found  in  the  neighbourhood  of  the 

epiphyses  ;  the  epiphyseal  car- 
tilage is  enlarged,  thickened,  and 
irregular ;  there  is  an  increase  in 
the  cartilaginous  elements  of  the 
.,  bone,  and  a  delayed  ossification ; 

,i>  *  ,  the  bones  are  weaker  and  less 

A        1>       *  rigid,  and  become  deformed  m 

^^       \- \      ' .  consequence.   The  ossifying  pro- 

cess is  delayed.  Changes  in  the 
shape  of  the  bones  of  the  head 
may  be  detected,  and  the  spine 
may  be  affected  by  kyphosis  ; 
the  teeth  do  not  erupt  till  late, 
and  are  stunted.  Changes  in 
the  ribs  are  produced  by  en- 
largement of  the  costochondrial 
junctions  (beaded  ribs),  which 
when  present  on  both  sides  of 
the  sternum  produce  what  is 
known  as  the  rickety  rosary. 
The  principal  changes  met  with 

Fig.  144.— Wrist  and  hand  of  child,  showing  changes      radiographically      are       at      the 
in  lower  end  of  radius  and  ulna  due  to  rickets.  •    ^  it  p      ,i         t 

epiphyseal  lines  of  the  long 
bones  and  the  adjacent  joint. 
Aehrondroplasia. — A  curious  congenital  condition,  resembling  rickets, 
in  which  the  growth  of  the  osseous  tissue  on  the  shaft  side  of  epiphysis  of  the 
long  bones  of  the  arm  and  of  the  leg  is  affected,  so  that  the  limbs  are  short 
and  stunted,  and  the  stature  correspondingly  diminished,  although  the 
epiphyses  are  normal. 

Simple  Atrophy  of  Bone.— This  results  from  a  variety  of  conditions, 
quite  independent  of  rarefying  inflammation,  in  which  it  is  a  marked  feature. 
It  may  be  congenital,  or  may  be  due  to  : 


PLATE  XXIV. — Tubercular  Disease  of  the  Hip-joint. 


a,  Tubercular  disease  of  hip-joint  affecting  chiefly  the  upper  part  of  acetabulum. 

h.  Tubercular  disease  of  hip,  absorption  of  head  and  greater  part  of  neck,  upward  displacement  of  femur. 
(Radiograph  by  Dr.  Salmond. ) 

c,  Later  stage  of  tubercular  disease  of  hip-joint,  disorganisation  and  displacement  of  head,  large  abscess 
on  outer  side  of  shaft  of  femur. 


CONDITIONS  PREDISPOSING  TO  FRACTURE  173 

(a)  Interference  with  the' epiphysis,  as  in  rickets,  or  injuries,  or  as  a 
sequence  to  tuberculosis  or  other  inflammation,  involving  the  function  of  the 
cartilage. 

(6)  Injury  or  disease  of  the  nervous  system  or  of  peripheral  nerves,  as 
tabes  dorsalis,  syringomyelia,  leprosy,  etc. 

(c)  Want  of  use  as  in  a  paralysed  or  ankylosed  limb. 

(d)  Local  pressure,  as  of  a  tumour  growing  within  or  outside  the  bone. 

(e)  A  senile  change. 

These  conditions  are  illustrated  in  many  of  the  skiagrams  showing 
disease  of  bone  and  joints,  and  attention  is  called  to  them  as  they  occur. 

MoUites  Ossium  or  Osteomalacia. — A  condition  characterised  by  the 
absorption  of  the  osseous  substance  of  the  bones,  as  a  result  of  which  softening 
and  rarefaction  are  produced,  followed  by  bending  or  spontaneous  fracture. 
Pathologically  there  is  a  replacement  of  the  medullary  substance  by  a  soft, 
fibro-cellular  tissue,  which  is  exceedingly  vascular,  and  into  which  haemor- 
rhage may  occur.  Attention  may  be  called  to  this  condition  when  a  spon- 
taneous fracture,  or  fracture  from  slight  violence  occurs.  The  changes  in 
the  bone  can  be  shown  radiographically. 

Morbid  Conditions  of  Bone  which  predispose  to  Fracture.— It  is 
important  to  bear  well  in  mind  several  conditions  of  bone  which  predispose 
to  fracture.  When  fracture  from  slight  violence  occurs,  suspicion  should  at 
once  be  aroused,  and  the  examination  should  be  conducted  on  lines  which 
will  enable  the  radiographer  to  show  not  only  the  fracture,  but  also  the  con- 
dition which  has  predisposed  to  it.  For  this,  good  negatives  are  essential. 
A  picture  which  will  show  a  fracture  is  often  not  full  of  fine  detail,  without 
which  no  opinion  on  bone  disease  can  be  formed.  In  the  same  way  a  screen 
exam.ination  will  show  a  fracture,  but  an  opinion  of  the  bone  condition  can- 
not be  formed  from  it.  The  most  usual  conditions  predisposing  to  fracture 
are  : 

(1)  Atrophy  of  bone.  This  may  be  senile,  or  due  to  disease,  e.g.  anky- 
losis of  a  joint  or  certain  nervous  afiections. 

(2)  Fragilitas  ossium.  This  consists  in  an  inherited  tendency  to  spon- 
taneous fracture,  occurring  in  children  and  adults. 

(3)  Bone  disease,  such  as  tuberculosis,  rickets,  syphilis,  osteo-malacia. 

(4)  Local  bone  disease  or  tumours,  such  as  sarcoma,  secondary  car- 
cinoma. 

A  condition  which  frequently  leads  to  fracture  is  a  cystic  condition  of 
bone.  Many  examples  have  been  shown  of  late  years  occurring  in  the  long 
bones,  the  humerus  being  a  common  seat  of  this  tumour.  It  is  frequently 
a  very  slow  form  of  myeloid  sarcoma.  Elmslie  has  drawn  attention  to  this 
cystic  disease  of  bone,  and  shown  several  interesting  examples. 


DISEASES   OF  JOINTS 

These  are  numerous,  and  have  characteristics  which  may  often  be  shown 
by  radiography.  A  great  deal  of  light  has  been  thrown  upon  the  differential 
diagnosis  of  such  conditions  as  tuberculosis  of  joints,  chronic  arthritis,  gout, 
and  other  diseases  by  the  systematic  examination  of  joints  at  regular  in- 
tervals during  the  progress  of  the  disease.  The  various  forms  of  arthritis 
may  be  distinguished  one  from  the  other.  Acute  inflammation  of  a  joint 
may  be  shown  when  the  synovial  sac  is  seen  fully  distended  ;  later  the 
shadows  caused  by  the  fluid  will  become  denser  when  pus  forms.  The 
changes  in  cartilage,  especially  when  the  disease  is  chronic,  are  seen,  and 
later  the  bone  becomes  affected.  Radiographically  the  interspaces  between 
the  cartilages  are  increased  when  the  joint  is  full  of  fluid.  The  opposite  limb 
should  also  be  taken  in  order  to  determine  departures  from  the  normal. 

Tuberculous  Disease  of  Joints 

In  this  disease  the  departures  from  the  normal  are  marked.  The 
synovial  membrane  is  swollen  and  pulpy.  The  joint  is  very  much  enlarged, 
this  being  shown  when  the  joint  is  radiographed,  variations  in  the  density 
of  the  shadows  of  the  soft  parts  indicating  an  inflammatory  change 
in  the  synovial  membrane.  The  cartilage  becomes  eroded,  and  later  the 
process  extends  to  the  bone  itself,  which  may  be  shown  to  be  eroded.  In 
places  irregular  thickenings  of  the  bone  also  occur,  and  the  bone  in  the  vicinity 
of  a  joint  may  be  thickened  for  some  distance  up  the  shaft.  In  the  later 
stages  the  joint  shows  marked  disintegration,  with  a  synovial  cavity  filled 
with  caseous  material,  this  showing  in  the  radiograph  as  faintly  marked 
irregular  shading  within  a  greatly  swollen  joint. 

The  surrounding  bones,  especially  those  below  the  joint,  show  atrophic 
changes.  All  the  bones  entering  into  the  joint  become  affected.  All  stages  in 
the  history  of  tuberculous  disease  of  joints  may  be  demonstrated  by  radio- 
graphy. The  very  early  stages  are,  however,  the  most  difficult  on  which  to 
give  an  opinion,  and  clinical  evidence  should  always  be  taken  into  account 
when  an  opinion  is  required.  It  is  of  the  utmost  importance  to  be  able  to 
determine  the  presence  of  early  tuberculosis,  for  on  that  the  future  treatment 
depends.  In  joints  which  have  been  the  seat  of  recent  injury,  changes  due  to 
the  injury  may  be  detected,  and  these  may  later  become  the  centre  of  a 
tuberculous  infection.  Consequently,  when  examining  joints  after  injury  it 
is  important  to  be  able  to  distinguish  fine  changes  in  the  parts. 

174 


PLATE  XXV. — Tubercular  Diseases  of  Joints. 


a.  Tubercular  disease  of  lower  end  of  femur,  involving  diaphysis  and  epiphysis,  a  considerable  degree 
ot  sclerosis  of  bone  around  an  abscess  cavity. 

h,  Lateral  view  showing  the  same  changes.      (Radiographs  by  Dr.  R.  W.  A.  Salmond. ) 

c.  Tubercular  area  in  scaphoid.      (Radiograph  by  Dr.  R.  W.  A.  Salmond.) 

d,  Tubercular  disease  at  ankle-joint  ;  note  rarefaction  of  bones  of  foot. 


PLATE  XXVI. — Tuberculosis  of  Bones  and  Joints. 

a,  Tubercular  disease  of  bones  of  hand,  characterised  by  new  bone  formation  affecting  metacarpal  bones 
and  phalanges. 

h,  Tubercular  disease  at  end  of  radius,  localised  abscess.     (Radiograph  by  Dr.  R.  W.  A.  Salmond. ) 

c,  Tubercular  dactylitis  affecting  2nd  and  3rd  metacarpal  bones. 

d,  Tubercular  disease  at  upper  end  of  humerus  (caries  sicca).     (Radiograph  by  Dr.  R.  W.  A.  Salmond.) 


TUBERCULOSIS  OF  JOINTS 


175 


The  later  stages  of  tubercular  disease  are  much  easier  to  recognise  ; 
rarefaction,  caseation,  and  formation  of  pus  are  readily  distinguished.  A 
localised  rarefaction  of  bone  in  the  neighbourhood  of  a  joint  should  arouse 
suspicion  of  the  presence  of  pus,  particularly  when  the  bone  round  the  rarefied 
area  shows  a  tendency  to  condensation.  The  epiphysis  may  assume  a  worm- 
eaten  appearance,  which  is  distinctive  of  early  caries  ;  later  this  may 
completely  disappear. 

It  is  important  also  to  be  able  to  distinguish  between  tuberculous  and 
non-tuberculous   disease   of   bone.     In   acute   and  subacute   osteomyelitis 


Fig.  145. — Tuberculosis  of  left  hip-joint,  particularly  atfecting  the  acetabuluni.     Note  the  diiferencie 
between  the  two  joints  and  relative  shortening  of  neck  on  attected  side. 

afiecting  the  neighbourhood  of  a  joint,  and  particularly  in  the  latter,  the 
tendency  is  towards  the  formation  of  new  bone,  and  the  destructive  process 
is  not  then  so  manifest.  Irregular  thickening  of  the  periosteum  with  the 
deposition  of  new  bone  favours  a  diagnosis  of  non-tubercular  disease.  In 
some  cases  a  degree  of  caries  sicca  preponderates  iii  the  process,  and  then 
there  is  not  the  same  tendency  to  the  formation  of  an  abscess.  The  bone 
shows  rarefaction  for  a  considerable  distance  up  the  shaft.  An  accompanying 
degree  of  rarefaction  of  the  bones  entering  into  the  joint  results  from  the 
restriction  of  movement,  and  need  not  necessarily  be  taken  as  an  indication 
of  the  extent  of  the  disease.     Ankylosis  of  the  joint  may  follow  the  healing 


176  RADIOGRAPHY 

of  the  inflammatory  process.  Displacements  of  the  bones  may  result  from 
destruction  of  the  ends,  in  the  hip-joint  this  being  frequently  shown  as  a 
dislocation  upwards. 

Tuberculosis  may  be  met  with  in  practically  any  of  the  joints  of  the 
body,  those  most  frequently  affected  being  the  hip,  the  knee,  the  elbow,  the 
wrist,  the  ankle,  and  the  shoulder.  The  appearances  are  characteristic. 
The  spine  is  frequently  the  seat  of  a  tuberculous  caries  which  ends  in  abscess 
formation.     In  many  instances  the  presence  of  an  abscess  can  readily  be 


Fig.  146. — Arthritis  following  injury  of  knee-joint.     Lateral  view. 

There  is  a  breach  in  the  continuity  of  the  articular  surface  of  the  femur.  The  articular  surface 
of  the  patella  shows  slight  irregularity.  The  interarticular  space  between  the  femur,  head  of  the 
tibia,  and  the  patellar  ligament  is  occupied  by  chronic  inflammatory  products  indicated  by  a  mottled 
appearance  on  the  print.     There  is  a  sesamoid  bone  in  a  tendon  on  the  posterior  aspect  of  the  joint. 

This  print  shows  well  the  structure  of  the  bones  entering  into  the  knee-joint,  and  the  soft 
parts  are  very  well  shown.  This  quality  of  negative  should  always  be  obtained,  if  possible,  when 
examining  joints  for  it  gives  a  good  definition  in  all  the  parts. 

shown  on  radiographic  examination.  In  a  later  stage  a  considerable  degree 
of  deformity  occurs.  These  are  more  easily  shown.  The  early  stages  of  a 
tuberculous  inflammation  of  bone,  particularly  when  the  spine  is  affected,  is 
difficult  to  distinguish  from  a  tumour  involving  the  spine.  A  consideration  of 
the  history,  temperature  chart,  etc.,  will  help.  The  tumour  shadow  is  usually 
more  irregular,  and  generally  involves  the  circumference  of  the  bone,  while  an 
abscess  may  be  more  localised  at  one  part.  In  doubtful  cases  an  exploratory 
operation  is  to  be  recommended.  Simple  inflammatory  changes  in  a  joint 
are  commonly  the  result  of  traumatism.  An  acute  attack  quickly  subsides 
and  recovery  takes  place,  but  it  must  be  borne  in  mind  that  a  simple  injury 
may  end  in  chronic  inflammation,  which  may  later  become  the  seat  of  tuber- 


PLATE  XXVII. — Chronic  Arthritic  Changes  at  the  Knee-joint. 

a.  Rheumatoid  changes  in  knee-joint,  with  large  bony  deposit  in  front  of  femur. 

h,  Chronic  rheumatoid  changes  in  knee-joint ;  loose  bodies  have  formed  inside  the  synovial  membrane. 

c,  Knee-joint,  showing  extensive  changes  in  patella,  probably  the  result  of  traumatism. 


L008E  BODIES  IN  JOINTS  177 

culous  invasion.  In  joints  traumatism  may  lead  to  minute  changes  in  bone 
and  cartilage  which,  though  not  definite  enough  to  be  recognised  as  actual 
fractures,  may  yet  be  quite  as  serious  in  their  after  effects.  Ligaments 
may  be  torn  ;  this  may  occur  in  the  knee-joint,  when  the  crucial  ligaments 
are  torn.  There  may  even  be  a  fracture  of  the  spine  or  the  tibia.  These 
minute  changes  should  be  carefully  looked  for  in  all  cases  of  joint  injury. 

Atrophy  of  Bone  may  be  found  in  the  region  of  a  joint,  the  result  of 
disease  following  upon  tuberculosis  or  other  inflammatory  process. 

Chronic  Articular  Rheumatism 

This  affects  several  of  the  large  joints,  especially  the  knee  and  shoulder. 
The  hip- joint  is  also  affected.  Eadiographically,  the  joints  may  present  very 
little  change  and  show  practically  no  rarefaction.  In  very  chronic  cases 
there  may  be  some  irregularity  of  outline  of  the  articular  surfaces,  indicating 
partial  absorption  of  the  cartilage. 

Chronic  Articular  Gout 

The  radiographic  appearance  of  the  joints  may  not  show  much  change, 
except  that  the  articular  surfaces  may  be  unusually  close  together,  and  lack 
the  rounded  appearance  they  possess  when  covered  with  sound  cartilage. 
Deposits  of  uric  acid  are  occasionally  clearly  seen  in  the  radiograph,  forming 
a  mass  denser  than  the  soft  parts  but  not  nearly  so  dense  as  the  bone  itself. 
Fringes  of  the  sjmovial  membrane  may  become  detached  and  form  loose 
bodies  in  the  joint. 

Loose  Bodies  in  Joints 

These  are  occasionally  met  with.  The  following  description,  which,  gives 
the  most  usual  varieties,  will  be  found  useful  when  a  consideration  of  these 
bodies  is  called  for  : 

1.  Synovial  fringes  in  which  proliferation  of  cartilage  cells  has  occurred, 
leading  to  the  formation  of  a  nodular  mass,  which  is  at  first  pedunculated, 
and  is  then  cast  off  into  the  cavity  of  the  joint  by  rupture  of  the  pedicle. 
These  bodies  are  usually  composed  mainly  of  hyaline  cartilage,  with  bony 
material  in  the  centre  of  the  larger  ones.  They  may  become  ossified  through- 
out. They  vary  in  size  from  about  J-inch  diameter  up  to  1  inch  ;  the  larger 
ones  are  usually  longer  than  they  are  broad.  There  may  be  only  one  loose 
body  in  the  joint,  or  there  may  be  several  hundreds.  It  is  not  uncommon  to 
find  one  body  quite  loose,  and  one  or  more  still  attached  to  the  synovial 
membrane  of  the  same  joint. 

2.  Osteophytic  outgrowths  from  the  edge  of  the  articular  cartilage  may 
become  detached,  and  so  form  a  loose  body  in  the  joint.  These  bodies 
are  irregular  in  shape,  and  usually  consist  of  a  layer  of  cartilage  covering 
an  osseous  centre. 

12 


178  EADIOGRAPHY 

Varieties  1  and  2  usually  occur  in  cases  of  osteoarthritis. 

3.  A  portion  of  articular  cartilage  with  a  thin  layer  of  bone  may  become 
separated  from  the  femoral  condyle,  and  form  a  loose  body  in  the  joint 
cavity.     This  occurs  probably  as  a  result  of  injury. 

4.  A  blood-clot  in  the  joint  may  become  gradually  smaller  and  firmer, 
and  so  form  a  loose  body.     This  occurs  as  a  result  of  injury. 

5.  A  portion  of  the  synovial  membrane  may  become  thickened  and 
indurated  as  a  result  of  injury.  This  is  nipped  by  the  articular  surfaces 
during  the  movements  of  the  joint,  and  finally,  as  a  result  of  the  rupture 
of  the  pedicle,  the  body  becomes  loose. 

6.  In  tuberculous  disease  of  a  joint  one  or  several  loose  bodies  may  be 
found.  These  are  composed  of  tuberculous  material  in  the  thickened  synovial 
membrane. 

7.  Around  a  foreign  body,  such  as  the  end  of  a  needle,  fibrous  tissue  may 
be  formed.     This  and  the  preceding  type  of  loose  body  are  rare. 

8.  Partial  detachment  of  a  semilunar  cartilage  gives  rise  to  a  body  which 
hangs  into  the  joint.  As  this  is  usually  still  attached  to  the  bone  it  cannot 
be  said  that  it  is  a  true  loose  body.  It,  however,  gives  rise  to  symptoms 
of  a  loose  body  in  the  joint. 

9.  An  innocent  tumour,  such  as  a  Hpoma,  may  form  in  the  synovial 
membrane,  become  pedunculated,  and  so  hang  into  the  joint  cavity.  This 
is  very  rare. 

10.  A  foreign  body,  such  as  a  nail,  bullet,  or  needle,  may  in  rare  instances 
form  a  variety  of  loose  body  in  the  joint.  These,  however,  are  usually  spoken 
of  as  "  foreign  "  bodies. 

Rheumatoid  Arthritis  or  Rheumatic  Gout 

This  is  characterised  by  marked  deformity  in  a  typical  case.  Eadio- 
graphically,  the  articular  ends  of  the  bones  present  the  normal  degree  of 
translucency,  or  they  may  be  more  translucent,  but  there  are  irregular, 
knob-like  projections,  some  of  which  appear  more  transparent.  The  joints 
may  become  ankylosed,  and  there  is  then  continuous  bony  structure  right 
through  the  joint. 

Hypertrophic  Arthritis  or  Osteoarthritis 

This  is  a  condition  described  separately,  but  it  is  probably  a  variety 
of  the  preceding  types,  characterised  by  a  tendency  to  the  formation  of  new 
tissue  between  bone  and  articular  cartilage,  which  becomes  calcified.  There 
may  be  marked  disorganisation  of  the  bones. 

Charcot's  Joints 

This  is  characterised  by  marked  enlargement  of  the  joint.  The  car- 
tilages are  eroded,  and  osseous  deposits  occur  in  the  ligaments,  with  irregular 
outgrowths  of  bone  around  the  joint. 


PLATE  XXVIII. — Diseases  and  Curvature  of  the  Spine. 


a,  Caries  of  cervical  vertebrae,  lateral  view. 
6,  Curvature  of  upper  dorsal  spine  (scoliosis). 
Curvature  of  spine,  involving  lower  dorsal  and  lumbar  vertebrae. 
d,  Caries  of  lumbar  vertebrae  and  sacrum. 


DIFFERENTIAL  X-RAY   DIAGNOSIS   IN   DISEASES 
OF   BONES   AND   JOINTS 

It  is  important  to  be  able  to  suggest,  if  only  tentatively,  a  differential 
diagnosis  in  morbid  conditions  of  bone,  and,  when  the  disease  is  near  a  joint, 
also  of  the  condition  of  the  joint.  The  tumours  of  bone  most  likely  to  com- 
plicate a  diagnosis  are  (1)  sarcoma,  (2)  cancer.  The  latter  is  generally 
accompanied  by  a  primary  lesion  elsewhere,  but  the  former  frequently  arises 
primarily  in  the  periosteum  (periosteal  sarcoma)  or  in  the  substance  of  the 
bone  (endosteal  sarcoma). 

It  is  necessary  to  consider  the  appearances  presented  by  tumours  of 
bone  when  dealing  with  what  appears  to  be  an  inflammatory  condition. 
The  subject  will  be  dealt  with  more  fully  later.  Tumour  of  bone  may  be 
complicated  by  superadded  inflammatory  changes  which  lead  to  still  greater 
difE.culties  in  diagnosis. 

Sarcoma  usually  attacks  the  shaft  of  the  bone,  and  produces  changes 
similar  to  those  caused  by  certain  degrees  of  osteomyelitis,  diflering,  however, 
in  that  the  latter  show  a  more  pronounced  degree  of  periosteal  reaction,  as 
indicated  by  the  deposition  of  new  bone  and  the  tendency  to  formation  of 
sequestra.  In  medullary  sarcoma  certain  areas  of  increased  density  appear 
which  resemble  spiculee  or  islands  of  osseous  material,  and  show  actual 
absorption  of  the  bone,  with  very  few  or  no  normal  portions  of  bone 
remaining  about  this  point.  In  osteomyelitis,  in  addition  to  the  more 
definite  thickening  of  the  periosteal  shadow,  there  is  a  more  definite 
formation  of  new  bone  about  the  necrosed  area. 


Appearance  of  Joints  in  Tuberculosis 

When  examining  joints  for  evidence  of  tuberculosis  the  following 
symptoms  should  be  looked  for.  They  are  met  with  in  the  course  of 
many  examinations  of  these  cases.  The  earliest  changes  are  naturally  the 
most  difficult  to  recognise. 

(1)  Marked  porosity  of  the  bones  forming  the  affected  joint. 

(2)  Actual  loss  of  substance  in  the  head,  e.g.  of  the  femur. 

(3)  Actual  loss  of  substance  in  the  hollow  bone,  e.g.  the  acetabulum. 

(4)  Extreme  atrophy  of  the  shaft  of  the  bone. 

(5)  Abscess  formation,  characterised  by  an  increase    of  the  normal 

179 


180  KADIOGKAPHY 

shadow  of  soft  parts  around  the  joint,  accentuation  and  bulging  of  the 
joint  outline. 

(6)  Necrosis  of  portions  of  the  bones,  with  formation  of  sequestra. 

(7)  Arrested  development  of  epiphysis,  and  changes  at  epiphyseal 
line. 

(8)  Displacement  of  bones,  particularly  at  hip-joint.  Where  the  head 
or  neck  of  the  femur  is  displaced  upwards  this  indicates  that  there  is  a  marked 
change  in  the  acetabulum. 

(9)  Ankylosis  of  the  bones  forming  the  joint. 


Tubercular  Dactylitis 

This  is  characterised  by  enlargement  of  the  affected  bones,  deformity, 
and  destruction  of  bone  tissue.  Enlargement  of  the  bone  is  often  accom- 
panied by  rearrangement  of  the  structure  of  the  bone.  Variations  in  density 
give  the  appearance  of  cysts  in  bone,  the  bone  surrounding  a  rarefied  area 
becoming  sclerosed  in  parts  ;  hence  the  cystic  appearance. 


Syphilis  of  Bone 

(1)  Periosteal  proliferation  leads  to  considerable  thickening,  irregular  in 
character. 

(2)  Areas  of  increased  rarefaction  due  to  marked  absorption  of  the  lime 
salts,  with  an  effort  towards  new  bone  formation. 

(3)  Periostitis  leads  to  many  layers  of  new  bone  being  laid  down  along 
the  whole  length  of  the  bone.  Generally  multiple,  it  therefore  affects  many 
of  the  long  bones. 

In  other  cases  the  thickening  may  be  localised,  causing  areas  of  dense 
new  bone  formation. 


Syphilitic  Dactylitis 

This  is  characterised  by  periosteal  overgrowth,  with  little  or  no  apparent 
disturbance  of  the  bone,  the  appearance  presented  by  this  condition  afford- 
ing a  fairly  reliable  diagnostic  point  in  favour  of  syphilis. 


Chronic  infective  Osteomyelitis 

(1)  General  infiltration  causes  a  deeper  shadow  about  the  bone  and  joint 
when  the  disease  appears  in  the  vicinity  of  the  latter. 

(2)  Periosteal  infiltration  and  overgrowth  lead  to  marked  increase  of  the 
adjacent  bone,  and  this  sclerosed  bone  appears  to  be  much  denser  than  normal 
bone,  and  the  shadow  is  greatly  increased  in  area. 


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OSTEOMYELITIS  181 

Acute  Osteomyelitis 

The  earliest  X-ray  appearance  of  an  osteomyelitis,  which  may  run 
through  all  the  stages  of  the  disease  in  a  few  weeks,  may  be  an  area  of  rare- 
faction at  the  epiphyseal  line,  commencing  in  the  diaphysis,  and  later  in  some 
cases  extending  into  and  involving  the  epiphysis.  This  ls  followed  by 
periosteal  thickening,  necrosis  of  bone,  evidenced  by  areas  of  varying  density, 
indicating  sequestra.  The  disease  may  become  localised,  when  radiographic- 
ally  it  is  shown  by  an  area  of  lighter  shading  surrounded  by  a  periphery  of 
denser  bone.  The  condition  may  arise  near  the  epiphyseal  line.  Abscess 
of  bone  may  be  the  result  of  the  inflammatory  process,  a  typical  instance 
being  the  well-lmown  abscess  in  the  upper  end  of  the  tibia  or  lower  end  of 
the  femur. 

In  the  hip-joint  a  mixed  infective  process  may  give  rise  to  appearances 
which  have  to  be  differentiated  from  tuberculous  cases.  Though  the  appear- 
ances may  indicate  a  preponderance  of  evidence  in  favour  of  one  or  other  of 
these  diseases,  it  is  not  always  possible  to  distinguish  between  them.  A  condi- 
tion where  there  is  a  tendency  to  proliferation  of  periosteum,  thickening  of  bone 
and  osteophytic  outgrowth  is  more  in  favour  of  a  non-tuberculous  condition. 
It  must  not  be  overlooked,  however,  that  a  condition  which  commenced  as  a 
tuberculous  one  may  become  the  seat  of  a  mixed  infection  or  vice  versa.  An 
infective  area  of  inflammation  may  become  the  seat  of  a  subsequent  tuber- 
culous lesion.  Marked  evidence  of  bone  disease  in  the  vicinity  of,  but  not 
involving,  a  joint,  is  rather  an  indication  for  a  diagnosis  of  a  non-tuberculous 
origin  for  the  disease.  A  typical  case  may  occur  in  the  upper  end  of  the 
femur,  when  an  area  of  lessened  shadow  {i.e.  a  condition  which  allows  of 
the  readier  passage  of  the  rays  through  the  bone  substance)  is  due  to  a 
destructive  process  in  the  bone,  with  absorption  of  the  bony  salts.  This  is 
accompanied  by  a  greatly  thickened  periosteum.  The  bone,  therefore,  appears 
on  examination  to  be  denser  in  the  surrounding  areas,  in  contradistinction 
to  the  general  rarefaction  which  is  so  frequently  seen  in  chronic  cases  of 
tuberculosis. 

The  typical  X-ray  picture  of  a  case  of  chronic  osteomyelitis  in  an 
advanced  condition,  when  the  whole  of  the  shaft  of  a  bone  has  become 
involved,  shows  : 

(1)  Areas  of  suppuration  indicated  by  patches  of  varying  density,  rare- 
faction of  bone,  and  small  collections  of  debris  and  pus. 

(2)  Newly  formed  periosteal  bone,  shown  by  the  deposition  of  successive 
layers  of  bone  outside  the  shadows  of  the  original  bone  or  what  remains  of  it. 

(3)  Necrosis  of  the  cortical  bone,  indicated  by  irregular  patches  of 
denser  shadow,  with  a  well-defined  periphery,  beyond  this  being  lighter 
shadows,  where  the  living  bone  still  remains. 

Generally  these  conditions  are  confined  to  the  shaft  of  the  bone  involved, 
the  epiphyses  and  joints  escaping.  The  earliest  X-ray  manifestation  is 
shown  by  a  slight  increase  in  the  periosteal  shadow  at  one  or  more  spots, 
a  definite  swelling  of  the  soft  parts,  and  possibly  abscess  formation. 


182 


EADIOGRAPHY 


Acute  infective  Periostitis 

The  diagnosis  by  X-rays  of  an  early  infection  of  the  periosteum  is  attained 
by  noting  changes,  such  as  thickening  and  bulging  of  the  periosteum.  The 
outline  of  the  periosteum  in  normal  bone  is  sharply  defined,  while  in  acute 
inflammatory  conditions  there  is  a  general  haziness  of  its  outline  in  the 
affected  part,  or  it  may  be  broken  and  irregular,  exposing  the  cortex  of  the 
bone. 

The  formation  of  an  abscess  is  shown  by  an  increased  depth  of  shadow  in 
the  neighbouring  soft  parts.  In  less  acute  cases  this  swelling  may  be  due 
to  inflammatory  changes  commencing  in  the  periosteum. 


Tumours  of  Bone 

The  simple  forms  of  tumour  are  often  diagnosed  with  ease,  but  the 
malignant  tumours  are  frequently  the  subject  of  great  doubt,  both  clinically 
and  radiographically.  The  latter  method  of  examination  is  often  called  upon, 
to  decide,  if  possible,  the  nature  of  a  doubtful  swelling.  In  all  such  cases 
great  care  must  be  exercised,  and  all  methods  of  examination  should  be 
employed.  To  make  a  positive  diagnosis  on  the  radiographic  appearance 
alone  is  often  misleading.     The  most  malignant  type  of  sarcoma,  for  instance, 

is,  in  the  early  stages 
at  least,  indistinguish- 
able from  a  simple  in- 
flammatory  process. 
Later,  more  decided 
features  may  be  made 
out,  but  it  must  be 
insisted  upon  that 
radiographically  it  is 
often  impossible  to 
decide.  The  clinical 
history,  the  radio- 
graphic evidence,  and 
in  most  of  the  early 
cases,  at  least,  a  fresh 
radiograph  of  the 
section  at  the  time  of 
operation  should  all 
be  employed.  The 
latter  method  puts 
the  nature  of  the  case 
beyond  all  doubt,  and  decides  at  once  the  extent  of  the  operation. 

The  clinical  and  radiographical  features  of  cases  of  tumour  will  be  dealt 


Pig.  147. — Sarcoma  of  lower  end  of  femur. 

The  bone  has  been  sawu  longitudinally  in  order  to  show  the 
tumour  in  its  interior.  The  appearance  of  this  tumour  in 
the  amputated  limb  and  in  the  living  subject  are  shown  in 
Plate  XXX.,  Figs,  c,  e,  and/. 


PLATE  XXX.— Tumours  of  Bone. 

a,  Periosteal  sarcoma  of  shaft  of  humerus.  Plate  XXXII  fig.  a,  shows  recurrence  in  lung  two  years  after 
amputation  of  arm.  h,  Myeloid  sarcoma  of  shaft  of  humerus  confirmed  by  microscopic  examination.  There 
have  been  several  fractures  at  the  seat  of  growth. 

c,  Sarcomaof  lower  end  of  femur  (after  removal),    d,  Sarcoma  of  head  of  fibula.    (Eadiograph  by  Dr.  Reid.) 

e,  Lateral  view  of  c,  from  living  subject.     ^,   Antero-posterior  view  of  c. 


TUMOURS  OF  BONE 


183 


with  later,  but,  in  passing, -it  may  be  observed  that  a  knowledge  of  the 
macroscopic  and  microscopic  appearances  of  tumours  will  aid  the  radio- 
grapher to  grasp  points  in  the  progress  of  a  case,  which  will  often  help  to 
decide  his  opinion  in  a  particular  instance. 

Sarcoma  is  the  most  important  primary  tumour  of  bone,  and  almost 
any  form  of  this  may  occur.  Endosteal,  or  central,  sarcoma  generally  com- 
mences in  the  medullary  cavity  or  cancellous  tissue,  and  results  in  the  so- 
called  "  expansion  "  of  bone,  which  consists  of  an  absorption  of  bone  from 
within,  whilst  at  the  same  time  new  osseous  tissue  is  being  deposited  from  the 


Fig.  148. 


-Choudro-sarcoma  of  lower  end 
of  tibia. 


under  surface   of    the  periosteum.  Fig.  149.— Sarcoma  at  upper  end  of  humerus.     This 

rrii            T              1  •                                      -ii  is    a   form    of   periosteal    sarcoma    which   rapidly 

The  radiographic  appearances  will  involved   the    soft  parts.      Radiographically,    the 

correspond   with  the  pathological  humerus    showed    very  faint    irregularity  at  the 

-,                     T^               .           J-    ,  1      T.  periphery  with  thickening  of  the  bone. 

changes.     Expansion  of  the  bone        ^ 

with  debris  in  the  centre  or  sarcomatous  new  tissue,  will  be  shown 
in  the  plate.  The  new  bone  forming  from  the  periosteum  is  de- 
posited in  more  or  less  definite  layers.  When  considerable  expansion 
of  bone  occurs,  it  can  readily  be  distinguished  from  inflammatory 
change  processes,  or  cysts  of  bone,  by  the  somewhat  sharp  nature  of  the 
expansion.  The  shaft  above  and  below  the  growth  is  normal,  and 
suddenly  expands  at  the  site  of  the  tumour.  The  growth  usually  com- 
mences at  the  end  of  a  long  bone.  It  seldom  encroaches  on  the  articular 
cartilage,  so  that  the  joint  escapes,  although  it  may  be  distended  with  fluid. 
Dr.  Emery,  of  King's  College  Hospital,  has  been  good  enough  to  report  on  the 
tumour  shown  in  Fig.  148.      It  consists  of  a  cellular  matrix,  composed  for 


184  EADIOGRAPHY 

the  most  part  of  large,  round,  or  oval  cells,  having  large  nuclei,  sometimes 
multiple.  There  are  also  a  few  myeloplaxes.  This  part  of  the  tumour  is 
sarcomatous  in  type.  Set  in  this  tissue  are  numerous  masses  of  cartilage, 
fairly  well  formed,  but  with  tumour  cells  (like  those  of  the  matrix)  instead 
of  ordmary  cartilage  cells.     The  tumour  is  a  chondro-sarcoma. 

Spontaneous  fracture  is  a  not  uncommon  comphcation,  and  owing  to  the 
expansion  of  the  bony  framework,  "  egg-shell  crackling  "  may  be  met  with. 
Later,  the  growth  may  expand  beyond  the  bony  limits  of  the  growth,  and 
secondary  deposits  occur,  the  substances  in  which  these  are  found  depending 
upon  the  type  of  the  primary  tumour.  The  lungs  and  mediastinum  are 
frequently  the  seat  of  secondary  growths. 

The  periosteal  type  of  sarcoma  is  not  at  all  easy  to  distinguish.     It  may 


Fig.  150. — Tumour  of  clavicle  (Radiograph  by  Dr.  R.  W.  A.  Salmoud). 

Sarcoma  of  acromial  eud  of  clavicle.     This  has  the  appearance  of  a  cystic  condition 
of  the  bone.     It  developed  rapidly. 

appear  as  a  decided  shadow  of  about  the  density  of  the  soft  parts,  arising 
from  the  surface  of  the  bone.  It  involves  the  soft  structures,  extending  into 
them  in  some  instances.  The  periosteum  may  show  thickening,  which  will 
be  revealed  radiographically. 

Myeloid  sarcoma  in  its  least  malignant  form  may  simulate  a  cyst  of  the 
bone.  It  is  of  slow  growth,  and  occurs  at  the  ends  of  long  bones.  Spon- 
taneous fracture  may  occur  in  this  as  in  cystic  disease. 

Hydatid  cyst  may  also  be  met  with.  It  is  more  chronic  in  its  progress, 
and  shows  a  well-defined,  fairly  regular  outline. 

Carcinoma  of  Bone. — This  is  usually  secondary  to  a  primary  focus 
elsewhere — in  the  breast,  genito -urinary  tract,  etc.  It  is  generally  a  late 
secondary  manifestation,  the  bones  most  frequently  afiected  being  the  ster- 
num, ribs,  and  spine.  The  disease  may  also  invade  a  large  joint,  or  the  shafts 
of  the  long  bones  become  involved.     The  sacrum  or  iliac  bones  may  also  be 


DIFFERENTIAL  DIAGNOSIS  OF  TUMOURS  OF  BONE       185 


invaded.  The  presence  of  these  secondary  deposits  is  shown  radiographically 
by  rounded  irregular 
shadows  of  varying 
density,  generally  lighter 
than  the  normal  bone. 
In  other  cases  the  disease 
takes  the  form  of  cario- 
necrosis,  when  cavities 
filled  with  necrosed  tissue 
are  produced,  and  ap- 
pear on  the  screen  or 
plate  as  lighter  areas. 

Exostoses. — These 
show  as  projections, 
sometimes  of  normal 
bone  tissue,  and  some- 
times of  rarefied  or 
unusually  dense  bone  ; 
the  situations  in  which 
they  are  met  with  are 
numerous,  as  in  the  ends 
of  the  long  bones,  bones 
of  the  feet,  the  pubis,  etc. 

Chondromata. — -These  may  occur  in  any  bone,  but  particularly  in  the 
long  bones,  and  also  in  the  bones  of  the  fingers  and  toes. 


Fig.  151. — Exostosis  of  lower  end  of  femur.  Shows  signs  of 
inflammatory  changes  at  end  of  exostosis,  probably  secondary 
to  trauma. 


Differential  Diagnosis  of  Tumours  of  Bone 

A  brief  summary  of  the  commoner  forms  of  tumour  of  bone  and  of  the 
points  which  are  most  useful  in  diagnosis  is  necessary.  It  is  also  well  to 
remember  that  there  are  no  positively  definite  signs  of  any  particular  tumour. 
Clinical  data  and  radiographic  records  should  be  taken  together  if  the 
examination  is  expected  to  be  of  value. 

The  appearance  of  a  shadow  of  doubtful  nature  in  one  of  the  long  bones 
raises  most  important  questions  of  diagnosis.  The  benign  cyst  has  recently 
been  shown  to  be  a  comparatively  common  tumour  of  bone.  The  term 
benign  is  used  in  relation  to  the  degree  of  malignancy  and  growth  rather  than 
as  a  pathological  classification.  Many  of  these  so-called  benign  growths  are 
myeloid  sarcomata,  which  are  peculiarly  slow  in  the  rate  of  growth.  The 
tumours  most  likely  to  lead  to  difl6.culty  in  diagnosis  are  those  which  are 
found  in  the  interior  of  the  shaft  of  a  long  bone,  or  at  its  epiphyseal  ends,  and 
which  have  rarefied  or  replaced  the  osseous  or  medullary  tissue,  with  or 
without  expanding  the  bone,  and  which  are  situated  within  the  osseous 
tissue  of  the  bone.  Such  tumours  may  prove  to  be  (1)  central  abscess, 
tuberculous  or  septic  ;   (2)  gumma  ;    (3)  hydatid  cyst ;    (4)  benign  cyst ; 


186 


RADIOGEAPHY 


(5)  fibrous  osteitis  ;  (6)  enchondroma  ;  (7)  endothelioma  ;  (8)  secondary 
carcinoma  ;  (9)  myeloma  ;  (10)  sarcoma. 

The  points  to  be  considered  are:  (1)  history;  (2)  physical  signs;  (3) 
evidence  of  disease  or  tumour  in  other  parts  of  the  body ;  (4)  radiographic 
appearances,  and  a  correct  interpretation  of  these.  The  chief  of  these,  so 
far  as  our  purpose  is  concerned,  is  the  radiographic  appearances,  though  all 
should  receive  attention. 

The  points  of  importance  radiographically  are  the  site  of  the  tumour 
in  the  bone,  its  density  and  consistence,  whether  subdivided  by  trabeculse, 
its  outline,  whether  sharply  defined  and  surrounded  by  a  well-defined  shell 


Fig.  152. — Traumatic  myositis  ossificans. 

Note  the  unchanged  aspect  of  the  bone.      The  ossification  in  the 
muscle  bundles  is  quite  distinct  from  the  periosteum. 


of  bone,  whether  the  bone  around  is  normal  or  rarefied,  presence  of  deposits 
of  new  periosteal  bone  or  sclerosed  bone,  the  presence  of  a  fracture,  the 
evidence  of  erosion  of  the  bone. 

Traumatic  Myositis  Ossificans. — A  condition  which  arises  in  the  sub- 
stance of  a  muscle  secondary  to  trauma.  It  occurs  most  frequently  in  the 
arm  or  the  thigh.  The  appearances  are  characteristic  and  must  not  be 
mistaken  for  sarcoma  arising  from  the  periosteum.  Fig.  152  illustrates 
the  typical  appearances  in  this  condition. 

Central  abscess  is  generally  accompanied  by  symptoms,  however  sHght, 
namely,  pain  and  loss  of  power,  indicating  an  inflammatory  process,  and 
occasionally  by  fluctuations  in  temperature.  Eadiographically,  the  cavity 
is  not  as  a  rule  strictly  central,  and  the  surrounding  dense  bone  is  unequal 
in  its  thickness.     The  outline  is  often  indefinite,  the  cavity  is  not  very  clear, 


PLATE  XXXI.— Tumours  of  Bone. 

«,  Secondary  sarcoma  affecting  upper   end  of  femur,   fracture  through  neck.     The  primary  lesion  was 
a  periosteal  sarcoma  of  humerus. 

h,  Same  case  at  an  earlier  stage.      (Radiograph  by  Dr.  N.  S.  Finzi.) 

c,  Sarcoma  of  upper  end  of  femur.     The  diagnosis  in  this  case  is  doubtful  ;  it  is  most  probably  a  myeloid 
sarcoma  of  very  slow  growtli. 

d,  Sarcoma  of  upper  end  of  humerus  (inset  is  a  photograph  of  the  joint  after  removal).     The  humerus 
has  Vjeen  fractured  probably  as  a  result  of  manipulation,  at  or  after  the  operation. 


DIFFERENTIAL  DIAGNOSIS  OF  TUMOURS  OF  BONE       187 

and  there  is  an  absence  of  trabeculae.  The  bone  around  is  denser,  and  there 
is  generally  a  deposit  of  new  bone. 

Hydatid  Cy.sL— This  is  very  rare  in  this  country,  though  it  should  always 
be  kept  in  mind  when  considering  obscure  conditions.  It  shows  as  a  sharply- 
rounded  area  less  dense  than  bone. 

Benign  Cyst  is  a  much  more  common  occurrence  than  was  formerly 
thought.  The  fiist  sign  may  be  a  so-called  spontaneous  fracture  of  the  bone, 
this  occurring  as  the  result  of  violence  of  a  mild  kind.  The  appearances 
are  characteristic.  The  cavity  or  cavities  are  situated  centrally  ;  they  fill 
the  bone  uniformly,  the  space  indicating  the  cyst  being  clear  and  not  sub- 
divided by  trabeculae.  There  is  little  or  no  sclerosis  of  bone,  and  no  periosteal 
thickening,  though  this  may  occur  as  a  result  of  fracture. 

Fibrous  Osteitis. — Probably  always  originates  in  early  life.  It  is  char- 
acterised by  swelling  and  deformity,  the  latter  being  due  to  bending  of  the 
softened  bone.  The  disease  may  be  localised  to  one  bone,  the  upper  end  of 
the  femur  being  the  most  frequent  site,  when  the  bone  is  expanded.  Skia- 
grams show  expansion  of  nearly  the  whole  shaft.  There  are  great  variations 
in  density,  and  an  appearance  of  subdivisions  by  trabeculse.  These  appear- 
ances lead  in  the  diagnosis  to  confusion  between  this  condition  and 
myeloma. 

Secondary  Carcinoma. — Radiographically,  there  may  be  seen  a  clear  area 
in  the  middle  of  the  shaft  of  a  long  bone  or  a  rib,  giving  the  appearance  of 
a  rarefied  patch  in  the  bone,  covered  by  a  thin  shell  of  compact  bone,  and 
fading  gradually  up  and  down  the  shaft  into  normal  bone. 

Myelo7na. — -They  are  most  likely  to  be  confused  with  benign  cyst  or  with 
fibrous  osteitis.  They  are  generally  found  at  the  ends  of  the  bones.  Radio- 
graphically,  the  distinguishing  features  are  the  expansion  of  the  bone  and  the 
subdivision  by  trabeculae. 

Sarcomata  of  Bone. — These  are  periosteal  and  endosteal.  The  former 
are  often  difficult  to  distinguish  from  inflammatory  thickening  or  myositis 
ossificans  traumatica. 

Medullary  Sarcoma  is  probably  the  rarest  of  the  endosteal  tumours 
of  bone.  The  bone  is  expanded  with  great  rapidity,  and  the  bony  shell  is 
'often  eroded.  Erosion  seen  in  a  skiagram  should  always  excite  suspicion  of 
the  true  nature  of  the  disease.  The  appearance  in  a  skiagram  of  a  clear  space 
in  the  shaft  of  a  bone,  expanding  the  bone  unequally,  and  showing  erosion 
of  the  bone  substance,  should  lead  to  the  suspicion  of  sarcoma. 


THE  X-RAY  EXAMINATION  OF  THE   THORAX  AND 

ITS   CONTENTS 

The  complete  routine  examination  of  tlie  thorax  includes  an  investigation 
of  the  bony  walls,  the  heart  and  aorta,  the  lungs,  the  mediastinum,  and  the 
oesophagus.  The  bony  walls  have  been  dealt  with  in  the  chapter  on  injuries 
of  bones,  and  the  oesophagus  in  that  on  the  alimentary  system.  For  our 
present  purposes,  therefore,  the  routine  examination  of  the  chest  consists  of 
a  scrutiny  of  the  heart,  the  lungs,  and  the  mediastinum  by  the  methods  of 
Radioscopy  and  Radiography. 

Radioscopy 

Radioscopy,  or  the  examination  of  a  patient  with  the  fluorescent  screen, 
is  a  method  of  great  value,  as  a  diagnosis  can  often  be  made  from  it  alone, 
to  be  subsequently  confirmed  by  radiographic  exposures.  To  obtain 
reliable  results  it  is  essential  that  the  technique  should  be  complete. 

Technique  of  Examination. — Several  methods  are  employed : 

1.  The  Recumbent  Position. — The  patient  may  be  placed  on  the  X-ray 
couch,  the  tube  working  from  below  and  the  operator  manipulating  the  screen. 
The  position  of  the  tube  and  of  the  diaphragm  aperture  are  adjusted  to 
suit  the  requirements  of  the  case.  It  is  essential  to  have  a  good  X-ray  tube 
of  the  proper  degree  of  hardness,  and  an  evenly-spread  fluorescent  screen. 

2.  The  Upright  Position,  with  the  patient  standing  in  front  of  the 
X-ray  tube,  is  undoubtedly  the  best.  For  this  method,  a  well-protected 
screening  stand,  all  the  parts  of  which  work  with  ease  and  smoothness,  is 
necessary.  The  particular  form  of  stand  varies  with  the  desires  of  the 
operator,  but  in  order  that  good  results  may  be  obtained  a  good  stand  is 
essential.  A  convenient  form  is  illustrated  opposite.  A  few  minutes'  con- 
sideration of  the  mechanism  will  familiarise  the  operator  with  its  move- 
ments, and  it  need  not  therefore  be  described.  A  rectangular  diaphragm  is 
better  than  one  of  the  iris  shape,  as  with  the  rectangular  form  it  is  possible 
to  examine  in  detail  the  roots  of  the  lungs  in  their  entirety. 

The  room  should  be  completely  darkened,  not  even  a  glimmer  of  light 
being  permissible  when  the  tube  is  working.  An  open  fireplace  for  heating 
purposes  is  not  advisable,  but  if  such  is  used,  then  efiicient  steps  must  be 
taken  to  exclude  light  from  it  during  the  examination.  It  is  also  necessary 
to  enclose  completely  the  X-ray  tube  and  valve  tubes  in  a  box  or  in  black 

188 


PLATE  XXXII. — Malignant  Diseases  of  the  Chest. 

a,  Secondary  deposits  of  sarcoma  iu  mediastinum  and  lungs. 

h,  Lynipho  sarcoma  of  mediastinum,  extending  outwards  from  root  of  lung  towards  the  periphery, 
c,  Secondary   deposits   of  cancer  involving  mediastinal  glands,   lung  substance,    and  pleura  ;    the 
diaphragmatic  surfaces  of  the  right  lung  and  the  liver  are  also  involved. 


EXAMINATION  OF  THE  THORAX 


189 


cloth,  and  even  the  front  of  the  X-ray  box  must  be  covered  with  an  opaque 
cloth,  if  reliable  observations  are  to  be  made. 

These  precautions  taken,  the  operator  should  allow  a  few  minutes  to 
elapse  in  the  darkened  room  before  the  current  is  allowed  to  pass  through 
the  tube,  in  order  that  the  retina  may  become  sensitive  to  the  fluorescent 
appearance  of  the  screen  when  the  tube  is  working:. 


Fig.  153. — Upright  screening  stand,  witli  automatic  stereoscopic  movements  of  tube-  and  plate- 
holder  controlled  from  the  switch-board.  Suitable  for  taking  radiographs  of  the  thorax. 
(Butt  and  Co.) 

The  Routine  Examination. — This  should  always  be  carried  out  in  a 
definite  order.  The  tube  should  be  first  centred  over  the  heart,  with  the 
diaphragm  opened  to  its  widest  limit.  This  enables  a  view  of  the  whole  of 
the  thorax  to  be  obtained.  Then  the  tube  should  be  carried  well  down, 
and  the  movements  of  the  diaphragm  examined  for  limitations  on  either 
side,  and  the  presence  of  dullness  at  either  base  looked  for. 

Next  the  heart  and  aorta  are  carefully  scrutinised  for  abnormalities  of 
size,  shape,  or  position,  or  for  the  presence  of  pulsation  in  abnormal  situations. 


190 


EADIOGKAPHY 


The  tube  should  then  be  moved  over  to  the  right  side  of  the  chest,  and 
the  diaphragm  of  the  apparatus  closed  laterally  until  a  long  slit  aperture  is 
obtained.  This  is  carefully  adjusted  over  the  hilus  of  the  lung  for  the 
detection  of  enlarged  or  cancerous  glands.  The  appearance  of  the  shadows 
at  the  root  of  the  lung  should  be  noted.  Repeat  the  observation  on  the  left 
side. 

Great  care  should  be  exercised  in  the  examination  of  the  apices  of  the 
lungs,  both  as  regards  the  quantity  of  current  passing  through  the  tube 

and  the  observation 
of  the  apices  them- 
selves. After  one 
apex  has  been  ex- 
amined a  mental 
note  should  be  made 
of  the  degree  of  the 
illumination  present, 
and  the  tube  then 
passed  over  to  the 
other  side.  Differ- 
ences between  the 
two  apices  should  be 
carefully  noted. 

The  current  pass- 
ing through  the 
tube  should  be  regu- 
lated by  the  operator, 
and  this  is  best  done 
by  an  adjustable 
rheostat  close  to  his 
hand.  With  a  soft 
tube  and  a  small 
primary  current,  very 
fine  detail  in  the  lung 
substance  can  be 
made  out.  This  is 
most  important,  for 
it  is  often  by  the 
examination  of  this  detail  that  a  diagnosis  of  early  tubercular  disease  may 
have  to  be  determined. 

Diagrams  may  be  made  on  the  lead  glass  in  front  of  the  fluorescent  screen 
of  any  particularly  striking  departure  from  the  normal,  alterations  in  the 
diaphragm  can  be  sketched  in,  and  the  amplitude  of  movement  on  inspiration 
and  expiration  noted.  A  permanent  record  of  the  amplitude  of  respiratory 
movements  of  the  diaphragm  can  be  obtained  by  getting  the  patient  to  inhale 
fully  and  hold  the  breath.  An  exposure  is  made.  Then  the  patient  exhales 
forcibly,  and  holds  the  breath  while  another  exposure  is  made.     The  two 


Fig.  154. — Thorax  of  an  adult,  showing  practically  a  normal  condition 
except  at  the  root  of  right  lung  where  there  is  a  slight  increase  of 
shadow.     (ExposLire  y-J-jj  sec.) 


PLATE  XXXIII. — Chest  showing  Pleural  Effusion  and  its  Absorption. 


Three  plates  from  the  same  patient  at  intervals  of  several  months. 

a,  Plate  on  anterior  asjiect  of  thorax,  shows  practically  a  normal  condition.  Note  level  of  diaphragm 
on  Ijoth  sides. 

h,  Effusion  at  left  base.     The  level  of  the  diaphragm  on  left  side  is  much  higher  than  in  above  plate. 

c,  The  eft'usion  has  been  absorbed  but  the  level  of  the  diaphragm  remains  higher,  indicating  the 
presence  of  adhesions  fixing  the  dome  of  the  diaphragm  on  the  left  side. 


EXAMINATION  OF  THE  THORAX 


191 


shadows  on  one  plate  show  the  degree  of  diaphragmatic  excursion.  All 
observations  of  this  kind  should  be  immediately  transferred  to  paper  on 
completion  of  the  examination,  and  entered  in  the  notes  of  the  case. 

These  observations  are  of  the  greatest  value  in  all  cases  ;  but  if  they  are 
to  be  useful  a  note  must  be  made  at  once,  otherwise  the  personal  element 
will  enter  largely  into  the  case.  Even  mider  the  most  favourable  conditions 
this  factor  must  be  considered,  since  it  is  the  great  objection  to  all  screen 
examinations.  In  no  other  region  of  the  body  are  we  so  absolutely  dependent 
upon  screen  examination  of  a  patient.  The  trained  eye  of  the  observer  may 
detect  changes  in  movement  in  lungs  or  heart  which  it  is  impossible  to  record 
upon  a  plate.  But  radiographs  which  are  taken  instantaneously  are  of 
great  value  as  confirmatory  evidence  of  changes  in  the  organs,  and  should 
always  be  taken  to  complete  the  examination.  The  importance  of  having 
a  thoroughly  reliable  fluorescent 
screen  must  be  borne  in  mind. 
It  is  also  essential  that  the  screen 
be  smooth  on  the  surface,  and 
kept  scrupulously  clean.  The 
lead  glass  protection  should  also 
be  kept  well  polished,  for  even  a 
trace  of  dirt  or  pencil  mark  on  its 
surface  may  lead  to  trouble,  the 
importance  of  this  point  being 
readily  understood  where  fine 
detail  is  being  dealt  with. 

It  is  also  of  importance  to 
have  the  patient  perfectly  still, 
especially  when  radiography  is 
employed,  since  the  slightest 
movement  during  the  exposure 
may  ruin  the  value  of  a  plate. 
The  screening  stand  should  be  connected  to  earth  by  a  wire,  in  order  to 
avoid  giving  the  patient  a  shock  from  the  electrical  discharges  which  are 
given  off  from  the  tube  and  metal  fittings  when  the  former  gets  hard. 


Fig.  155. — Normal  lower  cervical  aud  upper  dorsal 
vertebrfe,  showing  the  position  for  demonstration 
of  cervical  ribs.  The  apical  part  of  both  lungs  is 
also  well  shown. 


Radiography 

In  radiography  of  the  lungs  for  diagnostic  purposes  it  is  necessary  to 
use  a  soft  tube  in  order  to  obtain  the  best  results.  It  is  detail  in  lungs  and 
not  in  bone  that  we  look  for.  A  soft  tube  of  about  3-inch  spark-gap  will 
allow  a  large  quantity  of  current  to  pass  through  it,  and  will  give  very  good 
detail  in  the  soft  parts. 

Time  exposures  of  any  length  are  of  no  great  value  for  diagnosis  ;  if 
we  are  to  get  plates  which  will  to  any  extent  reproduce  what  we  have  seen 
on  the  screen,  the  exposure  must  be  exceedingly  short ;  in  fact,  the  shortest 
obtainable  is  the  best.     With  a  powerful  modern  installation  the  exposure 


192  KADIOGEAPHY 

may  be  cut  down  to  t^  of  a  second.  The  resulting  picture  is  of  great 
value,  because  everything  is  absolutely  sharp,  the  heart  being  represented 
in  outline  by  the  sharpest  possible  line.  The  diaphragm  is  also  sharp,  and 
may  be  caught  in  a  stage  of  contraction.  This  is  well  shown  in  a  print  from 
a  case  of  early  phthisis  (see  Plate  XXXV.,  Fig.  b). 

The  hilus  of  the  lung  is  also  well  shown.  The  branching  of  the  bronchi 
and  larger  vessels  can  be  followed  to  the  periphery,  and  if  the  tube  has  been 
in  the  proper  condition  a  faint  mottling  all  over  the  surface  represents  the 
lung  substance. 

From  a  comparison  of  such  pictures  obtained  from  normal  subjects  it 
is  quite  easy  to  detect  changes  which  occur  in  diseased  conditions,  especially 
in  the  very  early  stages  of  tuberculosis  of  the  lung.  Even  with  the  most 
up-to-date  apparatus  it  is  still  necessary  to  use  an  intensifying  screen,  if 
the  exposure  is  to  be  of  the  shortest  possible  duration.  With  a  screen  of 
this  kind  quite  good  pictures  may  be  obtained  with  much  less  powerful 
installations,  but  their  diagnostic  value  in  very  early  cases  is  not  nearly 
so  great. 

The  important  point  in  these  very  rapid  exposures  is  that  they  reproduce 
one  phase  of  what  one  sees  when  a  screen  examination  of  the  chest  is  made, 
with  all  the  movements  of  the  parts  eliminated,  so  that  when  compared  with 
the  result  of  a  prolonged  screening  they  afford  valuable  confirmatory  aid  to 
the  making  of  a  diagnosis.  Plates  taken  "svith  time  exposures  can  only  be 
of  value  when  a  gross  lesion  is  present.  Another  point  in  favour  of  these 
rapid  exposures  is  that  involuntary  movements  on  the  part  of  the  patient 
are  not  so  likely  to  spoil  the  result. 

In  radiography  of  the  thorax  and  bones  of  young  children  there  is  always 
difficulty  on  account  of  movements  during  the  exposures.  The  child  has 
often  to  be  held  on  the  plate.  The  rapid  exposure  is  of  great  value  in  such 
cases,  for  even  when  the  child  is  moving  a  sharp  radiograph  may  be  obtained, 
with  an  exposure  of  t^  of  a  second.  The  exposure  is  so  short  that  move- 
ment is  practically  eliminated  and  good  detail  is  obtained.  Short  exposures 
are,  therefore,  particularly  useful  in  radiography  of  the  thorax. 

Attention  to  Detail. — In  this  branch  of  the  work,  and  indeed  in  all 
branches,  only  the  most  careful  attention  to  detail  in  all  directions  will  aid 
us  in  the  production  of  reliable  pictures,  and  a  good  routine  is  essential. 
Mechanical  contrivances  which  facilitate  movements  of  apparatus,  and  enable 
us  to  reproduce  at  subsequent  examinations  the  same  relative  positions  of 
tube,  patient,  and  plate,  will  be  found  of  the  greatest  service.  The  fluor- 
escent screen  should  be  adaptable  for  the  ready  insertion  of  the  plate  when 
an  exposure  has  to  be  made.  Since  the  work  is  conducted  in  the  dark, 
all  metal  points  should  be  insulated  or  the  whole  apparatus  earthed,  and  all 
the  controlling  factors  must  be  at  hand.  Nothing  is  more  trying  than  work 
of  this  exacting  nature  with  the  factors  out  of  order.  Consequently,  great 
care  should  be  exercised  in  the  selection  of  all  apparatus,  with  all  the  features 
of  which  the  operator  must  be  perfectly  familiar. 

It  is  important  for  the  operator  to  have  control  of  the  X-ray  tube  when 


TECHNIQUE  OF  THORACIC  EXAMINATION  193 

screening.  A  convenient  form  of  regulator  is  the  Bauer  air- valve,  a  most 
ingenious  method  of  admitting  a  small  quantity  of  air  into  the  bulb,  the 
pressure  of  a  small  hand-pump  forcing  it  through  a  mercury  valve.  By 
this  contrivance  the  operator  can  regulate  the  hardness  to  the  requisite 
degree  without  stopping  the  examination. 

Experience  in  the  use  of  the  Bauer  air-valve  for  regulation  of  the 
vacuum  of  the  X-ray  tube  leads  to  the  conclusion  that  unless  great  care  is 
exercised  in  its  manipulation  the  tube  soon  becomes  hard,  and  requires  to  be 
constantly  regulated  when  in  action.  Other  forms  of  regulator  may  there- 
fore be  useful,  such  as  the  Osmosis  regulator,  where  a  small  gas  flame  can 
be  used  to  soften  the  tube.  The  control  pump  for  the  gas  supply  may  be 
placed  at  a  point  convenient  for  the  operator.  When  neither  of  these  regu- 
lators is  available  the  operator  must  regulate  the  tube  by  the  usual  method 
of  sparking  until  it  is  at  the  proper  degree  of  hardness  for  the  particular 
case  he  is  examining.  The  vacuum  can  then  be  kept  more  or  less  constant 
by  regulating  the  quantity  of  current  passing  through  the  tube  by  means 
of  the  regulating  rheostat.  It  is  a  good  practice  to  commence  the  screen 
examination  with  the  tube  slightly  on  the  hard  side.  A  prolonged  screening 
will  reduce  the  vacuum,  and  when  a  radiograph  requires  to  be  taken,  it 
will  be  found  that  the  tube  has  attained  the  requisite  degree  of  hardness. 
It  is  an  advantage  to  keep  one  tube  for  radiography  and  another  for  screening. 
The  Bauer  air- valve  is  figured  in  the  chapter  on  apparatus  (see  page  46). 
The  Bauer  regulator  is  also  attached  to  the  valve  tubes  when  these  are 
used.  The  two  hand-pumps  controlling  the  valve  and  X-ray  tubes  can  be 
placed  within  the  reach  of  the  operator.  The  control  table  may  also  be 
within  easy  reach.  A  foot  switch  to  control  the  lighting  of  the  room  is 
also  useful.  Then  the  operator  has  all  the  factors  under  his  personal  control 
during  the  screen  examination  of  the  patient. 

A  point  to  be  insisted  on  is  that  in  every  case  examined  a  consideration 
of  all  the  factors  in  the  case  is  essential,  and  a  diagnosis  should  never  be 
made  on  the  X-ray  appearances  alone.  The  physical  signs  are  most  im- 
portant, and  some  guide  should  be  given  by  the  physician  to  the  radiographer 
if  the  best  value  is  to  be  obtained.  The  findings  by  X-rays  are  frequently 
only  a  confirmation  of  an  opinion  already  formed.  It  is  true  that  in  some 
cases  the  extent  of  the  disease  may  be  greater  than  the  physical  signs  in- 
dicated, or  an  area  of  disease  may  be  shown  to  exist  in  unsuspected  regions, 
but  on  the  other  hand  radiography  may  fail  to  show  a  definite  lesion  when  all 
the  signs  and  symptoms  strongly  indicate  its  presence.  The  type  of  case 
which  most  frequently  calls  for  a  radiographic  investigation  is  that  of 
incipient  phthisis.  Tuberculosis  of  the  lung  in  all  its  varieties  and  stages 
will  fall  to  be  examined,  but  it  is  the  doubtful  case  which  proves  the  value 
of  radiography.  Here  the  rapid  exposures  will  help  greatly  in  settling 
the  diagnosis.  The  expert  clinician  can  foretell  changes  which  radiography 
may  fail  to  demonstrate,  but  the  fact  of  its  failure  does  not  negative  their 
presence. 

The  expert  radiographer  may  be   more  accurate  than  the  inexpert 

13 


194  KADIOGRAPHY 

clinician.  The  combination  of  the  expert  radiographer  and  the  expert 
clinician  cannot  fail  to  enhance  the  value  of  the  observations  of  each.  Cases 
will  occur  when  both  may  be  wrong.  Repeated  examinations  at  intervals 
by  both  may  show  the  changes  at  a  later  date,  and  the  record  furnished  by 
radiography  of  the  progressive  stages  of  a  disease  must  lead  to  the  accumula- 
tion of  knowledge  valuable  for  both. 

The  value  of  repeated  examinations  of  the  thorax  in  some  diseases  is 
shown  by  the  results  obtained  at  the  Cancer  Hospital,  London.  All  cases  of 
cancer  of  the  breast  and  other  parts  are  systematically  examined  at  intervals, 
valuable  evidence  being  thus  obtained  of  the  condition  of  the  pleura,  the 
roots  of  the  lungs,  and  the  mediastinum.  The  progressive  changes  caused 
by  secondary  deposits  in  the  pleura,  the  lungs,  and  the  mediastinum  are 
frequently  shown. 

Diseases  of  the  Thorax 

A  brief  consideration  of  the  pathology  of  conditions  affecting  the 
thorax  and  its  contents  is  necessary  before  discussing  the  radiographic 
appearances  and  the  differential  diagnosis.  This  review  must  necessarily 
be  brief,  for  it  is  not  within  the  scope  of  this  work  to  do  more  than 
mention  the  various  forms,  with  a  short  reference  to  the  macroscopic 
appearances  of  such  diseases,  their  common  situations,  and  some  points 
of  difference  in  their  origin  and  spread  which  have  a  bearing  on  the  radio- 
graphic interpretation.     The  conditions  that  will  be  referred  to  are  : 

(1)  Diseases  of  the  lungs. 

(2)  Diseases  of  the  pleura. 

(3)  Diseases  of  the  heart. 

(4)  Diseases  of  the  mediastinum. 

(5)  Malignant  disease  of  the  thorax,  including  tumours  of  the  heart 
and  pericardium,  the  lungs  and  pleura,  the  mediastinum,  the  oesophagus, 
the  spine,  and  the  chest  walls. 

(6)  Foreign  bodies  in  the  thorax. 

Diseases  of  the  Lung's. — As  these  are  classified  and  described  in  text- 
books on  pathology  and  medicine,  it  will  be  sufficient  to  recall  briefly  the 
chief  points  which  will  be  likely  to  aid  the  radiographer.  Many  of  them  are 
referred  to  in  the  section  dealing  with  the  differential  diagnosis. 

Circulatory  Disturbances  in  the  Lungs. — (1)  Congestion. — Two  forms  of 
congestion  are  recognised,  the  mechanical  and  the  hypostatic,  the  latter 
being  the  one  most  likely  to  show  signs  on  radiographic  examination.  All 
grades  of  change  may  be  seen  passing  into  consolidation. 

(2)  Broncho-Pneumo7iia. — The  lung  is  fuller  and  firmer  than  usual,  on 
section,  and  the  general  surface  has  a  dark-reddish  colour.  Projecting  above 
the  level  of  the  section  are  lighter-red  or  greyish-red  areas,  representing  the 
patches  of  broncho-pneumonia.  These  may  either  be  isolated  and  separated 
from  each  other  by  uninflamed  tissue,  or  they  may  be  in  groups,  or  the  greater 
part  of  a  lobe  may  be  involved.     The  disease  may  pass  on  to  the  stage  to 


PLATE  XXXIV. — Chests  showing  Pui,.m').\ai{y  Tuberculosis. 


a,  Right  apex  showing  advanced  consolidation  ;  left  apex  involved  but  disease  not  so  ad- 
vanced ;  roots  of  lung  both  involved  but  more  so  on  right. 

b,  Left   side  of   chest   extensively  involved  ;    both  apices  are  involved  ;    heart    small    and 
""vertical."     These  two  cases  are  both  affected  by  active  tuberculosis. 

c,  Healed  tuberculosis  of  long  standing  ;  both  apices  show  signs  of  involvement ;  roots  of 
lungs  show  evidence  of  calcified  glands.      Patient  had  no  active  symptoms. 


DISEASES  OF  THE  LUNG  AND  PLEURA  105 

which  the  term  splenisation  has  been  given,  when  it  may  be  accompanied 
by  a  condition  of  collapse  of  parts  of  the  lung. 

(3)  Chronic  Interstitial  Pneumonia  {Cirrhosis  of  the  Lung,  Fibroid 
Phthisis). — There  are  two  chief  forms,  the  massive  or  lobar  and  the  insular 
or  broncho-pneumonic  form.  In  the  massive  type  the  disease  is  unilateral, 
the  chest  of  the  affected  side  is  sunken  and  deformed,  and  the  shoulder  much 
depressed.  The  heart  is  drawn  over  to  the  affected  side,  the  unaffected 
lung  being  emphysematous,  and  covering  the  greater  portion  of  the  media- 
stinum. There  may  be  dense  adhesions,  and  the  pleural  membranes  may  be 
greatly  thickened.  In  the  broncho-pneumonic  form  the  areas  are  smaller, 
often  central  in  position,  and  are  found  most  frequently  in  the  lower  lobes. 

(4)  Lobar  Pneumonia  is  classified  by  physicians  amongst  the  specific 
infectious  diseases,  but  for  radiographic  purposes  it  may  be  described 
together  with  the  more  chronic  forms  of  pneumonia.  Three  stages  of  the 
process  of  inflammation  are  recognised :  (a)  engorgement,  (6)  red  hepatisation, 
(c)  grey  hepatisation.  In  red  hepatisation  the  lung  tissue  is  solid,  firm,  and 
airless,  it  may  be  friable,  and  the  surface  has  a  granular  appearance.  Grey 
hepatisation  is  a  further  stage  in  the  inflammatory  process,  and  it  may, 
though  rarely,  go  on  to  abscess  formation.  The  disease  is  usually  confined 
to  a  single  lobe  of  the  lung,  but  the  adjoining  lobes  may,  however,  be  con- 
gested, and  in  some  instances  the  whole  lung  or  both  lungs  may  become 
involved. 

(5)  Tuberculosis  of  the  Lungs. — All  forms  may  be  met  with. 
Diseases  of  the  Pleura.  —  These  require  to  be  briefly  considered, 

because  the  occurrence  of  one  or  other  of  them  may  give  rise  to  a  difficulty  in 
diagnosis  ;  and  also  in  the  course  of  a  malignant  tumour  of  the  lung,  pleurisy 
and  effusion  are  common  sequelae.  The  simple  form  of  pleurisy  is  easily 
recognised.  Heemorrhagic  pleurisy  may  occur  when  carcinoma  of  the  lung 
is  present.  Diaphragmatic  pleurisy  may  be  limited  partly  or  chiefly  to  the 
diaphragmatic  surface.  It  is  often  dry,  but  may  be  accompanied  by  effusion, 
either  serofibrinous  or  purulent,  which  is  circumscribed  to  the  diaphragmatic 
surface.  Serous  or  purulent  effusions  of  any  size  confined  to  the  diaphragm- 
atic surface  are  very  rare.  Encysted  pleurisy  may  lead  to  a  loculation  of 
the  resulting  empyema,  which  will  give  a  shadow  that  may  be  quite  indis- 
tinguishable from  that  caused  by  a  new  gro\^i:h  or  a  primary  abscess  of  the 
lung.  Interlobar  pleurisy  is  another  condition  which  must  be  borne  in  mind 
when  considering  a  doubtful  negative. 

Diseases  of  the  Heart. — Tumours  of  the  heart  are  rare,  but  there 
are  conditions  which  may  simulate  tumour,  and  which  must,  therefore,  be 
mentioned.     These  are  tuberculosis  and  syphilis. 

Tuberculosis  of  the  Heart.— This  occurs  as  :  (a)  scattered  miliary  tuber- 
culosis ;  {b)  large  caseous  tuberculosis,  extremely  rare ;  (c)  sclerotic 
tuberculous  myocarditis.  The  disease  generally  proceeds  from  a  mediastinal 
gland,  this  fact  being  important  from  a  radiographic  point  of  view. 

Syphilis. — Gummata  are  the  only  manifestations  of  this  disease  likely 
to  attract  the  attention  of  the  radiographer  in  the  cardiac  region. 


196  KADIOGEAPHY 

Diseases  of  the  Mediastinum. — In  simple  lymphadenitis  and  suppura- 
tive lymphadenitis,  the  glands  are  large  and  infiltrated,  but  are  not  usually 
dense  enough  to  cast  shadows  sufficient  to  complicate  a  diagnosis.  Suppura- 
tive lymphadenitis  may,  however,  lead  to  abscess  formation,  and  then  a 
large  shadow  may  be  found  due  to  the  presence  of  pus.  Both  these  conditions 
may  simulate  tumour.  Abscess  of  the  mediastinum  is  not  at  all  uncommon, 
.and  may  be  of  considerable  size.  It  is  secondary  to  an  infective  process, 
e.g.  erysipelas,  eruptive  fevers,  and  tuberculosis.  Indurative  mediastino- 
pericarditis  is  a  condition  in  which  the  pericardium  may  be  greatly  thickened 
by  a  great  increase  of  the  fibrous  tissue.  This  may  give  rise  to  changes  in 
the  mediastinal  shadows. 

Malignant  Diseases  of  the  Thorax. — The  tumours  most  commonly 
met  with  will  be  considered  first,  then  the  rarer  conditions,  and  finally 
tumours  involving  the  bony  structures  composing  the  walls  of  the  thoracic 
cavity,  namely,  the  vertebrae,  ribs,  sternum,  and  costal  cartilages,  will  be 
briefly  considered. 

Tumours  of  the  Heart  are  very  rare.  An  enlarged,  hypertrophied,  or 
dilated  heart  may,  however,  complicate  a  diagnosis  when  a  malignant 
process  is  situated  in  the  near  vicinity.  Primary  cancer  and  sarcoma  are 
extremely  rare.  Secondary  tumours — sarcomata  and  carcinomata — may 
occur,  either  directly  or  by  extension  from  the  pleura  and  pericardium. 
Calcareous  patches  occurring  in  a  greatly  dilated  aorta  may,  where  viewed 
laterally,  simulate  the  appearance  of  secondary  growths  in  the  mediastinal 
glands.  When  these  occur  the  outline  of  the  dilated  aorta  is  seen  as  a  rule, 
particularly  if  there  is  an  associated  condition  of  arteriosclerosis,  and  these 
shadows  should,  therefore,  be  capable  of  differentiation  from  the  more  serious 
condition  of  growth.  A  hydropericardium  may  lead  to  difficulty  when  the 
pleura  also  contains  fluid,  both  of  these  structures  becoming  involved  when 
there  are  secondary  deposits  of  mahgnant  disease  in  the  pleura. 

Tumours  of  the  Lungs  and  Pleura. — Primary  tumours  are  rare,  and  primr 
ary  cancer  or  sarcoma  as  a  rule  involves  only  one  lung.  Secondary  growths 
are  not  uncommon,  and  may  be  of  various  forms,  generally  following  tumours 
of  the  digestive  tract,  the  genito-urinary  organs,  or  the  bones,  and,  most 
frequently  of  all,  cancer  of  the  breast.  The  types  most  usually  met  with  are 
in  order  of  frequency  :  (1)  scirrhus  cancer  ;  (2)  epithelioma,  which  may  be 
primary  in  the  bronchial  tract ;  (3)  sarcoma  ;  (4)  fibroma  ;  (5)  enchondroma  ; 
(6)  osteoma  (very  rare).  The  lungs  may  also  be  involved  in  Hodgkin's 
disease.  The  primary  growth  generally  forms  a  large  mass,  which  may 
occupy  the  greater  part  of  the  lung.  It  may  by  extension  outwards  involve 
the  parietal  and  visceral  pleura.  The  tumour  mass  may  necrose,  and  a 
cavity  result.  The  diffuse  cancerous  growth  may  resemble  a  tuberculous 
pneumonia.  The  metastatic  growths  are  nearly  always  disseminated  ;  they 
may  vary  from  a  mihary  type  to  quite  a  large  growth,  and  all  variations  in 
size  may  be  met  with  in  the  same  patient.  The  symptoms  may  be  slight 
or  marked  according  to  the  accessory  lesions  which  accompany  the  new 
growth,  such  as  pleurisy  ;  this  may  be  dry  or  accompanied  by  effusion. 


PLATE  XXXV. — Chests  showing  Pulmonary  Tuberculosis. 

a,  Post-mortem  subject.      Note  fine  shading  iu  lung  substance.     Tuberculous  bronclio-pneumonia. 
h,  Early  tuberculosis  of  lungs,  iDeribroncliial  thickening,  irregularity  of  diaiDhragmatic  shadow  on  right 
side,  with  sharpness  of  all  detail.     Exposure  -^^jj  second,  intensifying  screen  used. 
c,  Acute  general  tuberculosis  of  both  lungs  (miliary  tubercle). 


TUMOURS  OF  THE  THORAX  197 

Tumours  of  the  Mediaslinum. — Cancer  is  the  most  common  form  of 
tumour  in  the  mediastinum.  There  are  three  chief  points  of  origin  :  the 
thymus,  the  lymph  glands,  and  the  pleura  and  lungs.  Primary  sarcoma 
is  more  frequent  than  primary  cancer.  Lympho-sarcoma  and  lymphadenoma 
frequently  give  rise  to  large  tumours. 

Tumours  of  the  (Esophagus. — The  most  common  tumour  is  epithelioma, 
and  it  occurs  more  frequently  in  males  than  females.  The  middle  or  the 
lower  third  of  the  oesophagus  is  the  most  usual  situation  in  which  the  growth 
is  found.  It  is  at  first  confined  to  the  mucous  membrane,  but  soon  breaks 
through  and  extends  into  the  mediastinal  tissue,  stricture  occurring  in  the 
lumen  of  the  tube.  Later  on,  w^hen  ulceration  of  the  mucous  surface  occurs, 
the  stricture  may  be  less  marked  than  in  the  earlier  stages.  In  the  course 
of  the  disease  the  oesophagus  above  the  growth  becomes  dilated,  and  a  degree 
of  hypertrophy  follows.  The  ulcer  may  perforate  the  trachea,  the  lung,  the 
pleura,  the  mediastinum,  the  aorta  or  one  of  its  branches,  or  it  may  erode 
the  vertebral  column. 

Tumours  of  the  Spine. — Tumours,  simple  or  malignant,  may  arise  in 
connection  with  the  spine,  the  ribs,  the  intercostal  spaces,  and  the  costal 
cartilages.  These  may  by  extension  involve  the  adjacent  organs,  and  when 
the  lungs  and  pleura  become  implicated  shadows  are  obtained  which  are 
indistinguishable  from  new  growths  of  primary  origin  in  those  structures. 
Conditions  involving  the  spine  which  may  lead  to  error  are  :  (1)  Tubercular 
caries.  In  the  early  stages  an  inflammatory  process  leads  to  thickening  and 
abscess  formation  which  simulate  new  growths  of  the  spine  ;  rise  of  tempera- 
ture and  other  signs  of  tuberculosis  should  be  looked  for.  (2)  Abscess 
following  caries  is  a  frequent  cause  of  difficulty  in  diagnosis.  (3)  Sarcoma 
arising  from  the  costal  cartilages  and  sternum  may  lead  to  the  formation 
of  a  definite  cystic  condition  indistinguishable  from  hydatid  cyst.  A 
hgemorrhagic  condition  in  the  tumour  may  simulate  the  appearance  presented 
by  a  cyst. 

Tumours  of  the  Chest  Walls. — Sarcomata  in  these  positions  are  occasion- 
ally met  with.  They  may  be  solid,  or,  when  growing  rapidly,  may  become 
cystic  or  hsemorrhagic,  and  when  examined  show  shadows  which  may  be 
mistaken  for  new  growths  of  the  lungs  or  pleura. 

Foreig'n  Bodies  in  the  Thorax. — Various  forms  of  these  may  be  met 
with,  particularly  in  children.  A  foreign  body  should  first  be  located  by 
means  of  the  screen,  and  stereoscopic  radiographs  taken  for  exact  localisation. 
If  an  operation  is  contemplated,  then  the  examination  should  be  repeated 
just  prior  to  the  time  of  operation,  in  order  to  obviate  the  risk  of  change  of 
position  of  the  foreign  body.  The  thorax  and  cervical  region  require  to  be 
carefully  examined  when  a  foreign  body  is  suspected  to  be  present.  Lateral 
pictures  are  useful,  particularly  when  the  foreign  body  is  located  in  the  upper 
air  passages. 


198  EADIOGRAPHY 

Differential  Diagnosis  in  Diseases  of  the  Lungs 

The  differential  diagnosis  of  these  conditions  is  always  difficult,  particu- 
larly from  a  purely  radiographic  point  of  view.  The  X-ray  findings  are 
usually  shadows  of  abnormal  growths,  invading  shadows  representing  the 
normal  structures,  and  it  is  often  on  slight  variations  of  these  normal  shadows 
that  a  diagnosis  may  be  made.  A  fine  departure  from  the  normal  may  be 
the  earliest  manifestation  of  a  commencing  new  growth,  and  its  presence 
may  be  detected  before  physical  signs  or  symptoms  call  attention  to  the 
presence  of  serious  mischief.  On  the  other  hand,  however,  it  is  occasionally 
found  that  persistent  symptoms,  such  as  pain,  slight  cough,  dyspnoea, 
may  be  present  for  months  before  the  presence  of  a  neoplasm  can  be  detected 
by  radiographic  examination.  This  is  particularly  evident  in  the  recurrent 
forms  of  carcinoma  after  operation,  where  pain  at  a  fixed  point  may  for  a 
very  long  time  be  the  only  sign  of  recurrence.  Later  this  may  be  followed 
by  the  demonstration  of  a  gradually  increasing  shadow,  or  a  slowly  accumu- 
lating pleural  effusion,  indicating  that  the  pleura  has  become  involved. 
The  occurrence  of  these  infiltrating  secondary  carcinomata  of  the  pleura  is 
interesting.  The  extension  is  usually  by  direct  continuity  from  the  chest 
wall,  the  growth  developing  through  the  intercostal  spaces,  slowly  involving 
the  pleura  on  the  parietal  aspect,  spreading  along  the  internal  aspect  of  the 
ribs,  and  forming  fiat  plaques  which  do  not  penetrate  to  any  degree.  These 
plaques  are  shown  as  fine  shadows  along  the  lines  of  the  ribs.  Fluid  is  slowly 
exuded  into  the  pleural  sac,  and,  later,  the  visceral  layer  of  the  pleura  becomes 
involved,  at  a  still  later  stage  the  lung  itself  becoming  invaded  by  masses 
of  slowly  increasing  size.  In  contradistinction  to  this  it  must  be  borne  in 
mind  that  the  secondary  invasion  of  carcinoma  may  begin  in  the  mediastinal 
glands  or  those  at  the  roots  of  the  lungs.  It  then  spreads  along  the  bronchial 
glands,  and  at  a  late  stage  of  the  disease  we  may  find  the  pleura  studded  with 
plaques  on  its  parietal  and  visceral  aspects,  with  an  accumulation  of  fluid 
in  the  pleural  sac,  the  mediastinal  glands  enlarged,  and  the  whole  of  the  lung 
riddled  mth  growtns  of  various  sizes.  Radiographically,  all  these  stages  of 
secondary  carcinoma  may  be  shown  in  the  same  case  if  examinations  are 
made  during  the  progress  of  the  disease.  The  various  progressive  stages  of 
this  form  of  malignant  disease  are  well  worthy  of  careful  study,  for  all  these 
forms  are  sure  to  require  investigation.  In  the  earlier  stages  it  is  extremely 
difficult  to  establish  a  diagnosis  on  radiographic  evidence  alone  ;  all  the  facts 
of  the  case  require  careful  consideration,  and  other  methods  are  helpful, 
particularly  in  some  cases  where  tuberculosis  may  be  the  alternative  diag- 
nosis, or  where  it  may  be  an  accompanying  condition.  The  combination  of 
the  two  diseases  is  rare,  but  they  may  occur  in  the  same  patient.  Haemo- 
ptysis may  be  a  determining  factor  in  the  diagnosis,  especially  if  it  occur  to 
any  extent.  Haemorrhage  to  a  marked  extent  from  a  secondary  carcinoma  is 
comparatively  rare,  whereas  in  tuberculosis  it  is  often  the  first  symptom  to 
call  attention  to  the  disease. 

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DIFFERENTIAL  DIAGNOSIS  IN  DISEASES  OF  THE  LUNOS  199 

the  chest  wall  are  fairly  common,  and  may  give  rise  to  shadows  which  have 
to  be  differentiated  from  tumours  of  the  pleura  and  lungs.  Such  tumours 
may  be  enchondromata  of  the  costal  cartilages  and  bones.  Osseous  tumours 
will  give  dense  shadows,  and  should  present  no  great  difficulty  in  diagnosis. 

Primary  Malig-nant  Growths  of  the  Lung". — These  are  rare,  but  they 
do  occur,  and  when  a  shadow  is  seen  in  the  thorax,  in  a  case  which  gives  no 
evidence  of  a  primary  lesion  elsewhere,  the  assumption  is  that  it  may  be  a 
primary  malignant  growth.  Before  the  diagnosis  is  made,  however,  every 
care  should  be  taken  to  investigate  for  a  primary  lesion,  and  the  whole  thorax 
should  be  carefully  examined,  particular  attention  being  paid  to  the  larynx, 
trachea,  and  oesophagus.  Primary  growth  in  the  oesophagus  is  frequently 
not  examined  until  late  in  its  course,  or  until  the  presence  of  secondary 
deposits  in  the  mediastinum  calls  attention  to  it.  A  large  endothelioma  may 
develop  in  the  mediastinum,  and  invade  the  lung  to  a  considerable  extent 
before  giving  lise  to  any  symptoms.  Tumours  of  this  type  are  of  singularly 
slow  growth,  and  tend  to  become  encapsuled.  The  shadow  given  by  these 
tumours  will  be  well  defined,  and  may  simulate  an  aneurism. 

Hodgrkin's  Disease. — This  produces  well-defined  shadows  in  the  media- 
stinum, and  when  the  bronchial  glands  are  involved  these  give  rise  to 
shadows  which  may  simulate  malignant  growth.  The  shadows  from  a  simple 
enlargement  to  a  most  pronounced  type  of  sarcoma  are  finely  graded,  and 
any  of  these  may  present  appearances  indistinguishable  from  a  well-marked 
malignant  invasion.  Time  and  clinical  observations  will  help  to  clear  up 
the  diagnosis. 

Lympho-sarcomata. — Malignant  growths  arising  in  connection  with 
and  having  the  structure  of  lymphatic  tissue  are  not  infrequently  found  in 
the  mediastinum,  invading  the  root  of  the  lung.  They  tend  to  produce 
metastases,  and  may  be  very  malignant ;  when  well  advanced  they  lead  to 
rapid  emaciation. 

Sarcoma  of  the  Lung". — This  generally  arises  in  the  glands  of  the  media- 
stinum, and  spreading  into  the  lung  substance  by  direct  extension,  the 
tumour  tends  to  becomiC  solid,  and  may  eventually  compress  the  lung 
towards  the  periphery.  Sometimes  there  is  a  rapid  spread  of  metastases  all 
over  both  lungs.  This  type  of  tumour  is  frequently  secondary  to  a  lesion 
elsewhere.  From  a  radiographic  point  of  view  it  is  often  impossible  to 
distinguish  between  sarcoma  and  endothelioma  and  secondary  carcinoma. 
The  history  of  an  operation  for  removal  of  carcinoma  or  sarcoma  of  another 
part  of  the  body  will  often  settle  the  diagnosis.  A  rapidly-gromng  sarcoma 
m.ay  be  disseminated  all  over  the  lung  and  pleura,  but  in  the  early  stages  the 
nodules  will  be  small,  and  may  simulate  a  miliary  tuberculosis. 

The  clinical  history  is  generally  shorter  in  acute  phthisis  than  in  sarcoma. 
In  secondary  carcinoma  the  nodules  are  generally  larger,  tend  to  become 
more  irregular,  and  may  in  early  stages  be  more  located  to  the  periphery 
or  central  portions  of  the  lung,  while  the  presence  of  pleurisy  or  a  chronic 
pleural  effusion  should  help  in  the  establishment  of  a  diagnosis.  An  acute 
lobar  pneumonia  will  give  a  well-defined  shadow,  generally  confined  to  one 


200  RADIOGEAPHY 

lobe  or  a  part  of  a  lobe  of  the  lung.  A  few  days  will  suffice  to  clear  up  the 
diagnosis,  but  when  the  pneumonic  process  is  slow  to  resolve,  and  the  lung 
tends  to  fibrosis,  then  a  condition  arises  which  may  lead  to  serious  errors  in 
prognosis  if  full  consideration  is  not  given  to  all  the  facts  of  the  case.  Other 
forms  of  pneumonia  may  lead  to  difiiculty  in  diagnosis,  and  it  must  be 
remembered  that  a  patient  suffering  from  primary  or  recurrent  cancer  is  in 
a  debilitated  state  of  health,  and  in  consequence  rather  prone  to  develop 
broncho-pneumonia.  This  may  be  a  terminal  stage  of  the  disease,  even  when 
recurrence  has  located  itself  in  the  lung ;  the  apparent  extent  of  the  mischief 
may  be  greatly  exaggerated  by  a  concurrent  attack  of  broncho-pneumonia. 
When  radiographs  of  such  a  condition  are  taken,  a  grave  error  in  prognosis 
may  be  made  if  a  large  shadow  in  the  lung  substance  is  mistaken  for  a  malig- 
nant deposit ;  further,  the  subsequent  resolution  of  a  pneumonic  process 
may  give  the  impression  of  an  improvement  in  the  condition  of  the  patient, 
and  a  subsequent  shrinkage  of  the  shadow  may  lead  to  the  erroneous  conclu- 
sion that  the  tumour  itself  is  disappearing.  Similarly  a  pleural  effusion,  with 
thickening  of  both  layers  of  the  pleura,  may  give  the  impression  of  an  actual 
new  growth  in  the  lung.  Tapping  of  the  pleural  sac  and  withdrawal  of  the 
fluid,  with  a  resolution  of  the  inflammatory  process,  may  be  another  source  of 
error  in  diagnosis  and  prognosis.  Haemorrhage  into  the  lung  substance  may 
also  simulate  a  growth  of  considerable  size. 

Infarction  of  the  Lung"  (Pulmonary  Apoplexy). — This  condition 
comes  on  suddenly,  and  may  be  accompanied  by  pain  and  signs  of  pulmonary 
embarrassment.  The  examination  of  a  patient  after  the  symptoms  have 
subsided  may  show  a  fairly  well-defined  shadow  in  the  lung  substance,  which 
gives  rise  to  grave  suspicions  when  the  patient  is  already  the  subject  of  a 
cancerous  invasion. 

Tuberculosis. — As  already  stated,  tuberculosis  of  the  lung  may  be  met 
with  in  all  its  stages,  the  later  stages  being  readily  recognised  by  the  gross 
departure  from  the  normal.  In  very  early  or  incipient  cases  of  phthisis  it 
is  more  difficult  to  make  positive  statements,  but  the  combined  findings  of 
the  clinician  and  radiographer  are  most  helpful. 

The  various  forms  of  tuberculosis  met  with  in  the  pulmonary  system 
require  to  be  dealt  with  in  the  differential  diagnosis.  Cases  with  enlarged 
bronchial  glands  will  cause  some  difficulty.  The  peribronchial  forms  of 
phthisis  give  rise  to  marked  increase  of  the  hilus  shadows,  which  are  extremely 
difficult  and  often  impossible  to  differentiate  from  new  growth.  The  chief 
point  of  distinction  between  the  two  lies  in  the  fact  that  in  the  peribronchial 
form  of  phthisis  the  increase  of  shading  is  more  evenly  distributed  at  both 
roots,  and  may  extend  up  to  the  apex  or  down  to  the  base  of  the  lung, 
forming  "  tree  root  "  shadows,  with  nodular  enlargements  of  small  size,  the 
latter  indicating  the  presence  of  calcified  or  fibrosed  bronchial  glands.  When 
a  recurrence  of  cancer  occurs  at  the  roots  of  the  lungs  it  tends  to  be  more 
definitely  localised  to  one  spot,  and  spreads  outwards  into  the  lung  substance, 
while  the  remaining  portion  of  the  bronchial  tree  on  that  side  may  show  no 
marked  increase.     The  bronchial  ramification  on  the  other  side  is  generally 


PLATE  XXXVII. — Chests  showing  Changes  in  Heart  and  Lungs. 


a,  Lobar  j)nenmonia,  localised  to  right  upper  lobe. 

h,  Secondary  carcinoma  of  mediastinum  spreading  out  into  lung  substance. 

c,  Greatly  enlarged  heart.     Hypertrophy  and  hydropericardium. 


TUBERCULOSIS  OF  THE  LUNGS  201 

free.  A  bilateral  increase  of  shadows  is  more  in  favour  of  a  tuberculous 
condition  than  a  malignant  growth.  The  tuberculous  condition  may,  how- 
ever, be  present  in  a  patient  who  subsequently  develops  a  cancer  or  a  sarcoma 
of  the  lung. 

When  disease  has  been  shown  to  be  present,  it  is  often  difficult  to 
determine  whether  it  is  active  or  not.  The  distinction  between  active  and 
healed  tuberculosis  has  often  to  be  made.  In  the  former  the  mottling  of  the 
lung  shadows  is  more  marked,  in  the  latter  the  appearances  conveyed  are 
more  those  of  streaking,  indicating  a  fibrotic  condition.  In  some  cases  the 
shadows  appear  to  be  denser,  and  occasionally  it  is  possible  to  make  out 
areas  of  calcification.  These  ruay  be  seen  at  the  apices,  but  more  frequently 
at  the  root  of  one  or  both  lungs. 

Jordan  has  drawn  attention  to  the  appearances  of  the  hilus  shadows 
when  he  states  that  a  great  number  of  cases  examined  showed  peribronchial 
thickening.  He  ascribes  this  condition  in  nearly  every  case  to  the  presence 
of  tubercle,  and  states  that  nearly  all  the  cases  he  examined  showed  a  con- 
dition of  this  kind.  When  these  bronchial  shadows  are  accompanied  by 
mottling  the  condition  is  said  to  be  active.  He  also  contends  that  in  the 
majority  of  cases  the  disease  started  at  the  hilus  by  an  infection  of  the 
bronchial  glands,  and  an  extension  from  these  glands  takes  place  towards 
and  involving  the  apex. 

Bythell  records  the  results  of  an  examination  of  several  hundreds  of 
children.  He  found  in  a  large  percentage  of  these  cases  signs  of  tubercu- 
lous infection  in  the  glands  at  the  roots  of  the  lungs. 

While  admitting  that  in  the  examination  of  a  large  number  of  cbests 
these  shadows  are  to  be  seen,  the  writer  cannot  agree  that  a  diagnosis  of 
tuberculosis  can  be  made  in  every  case.  It  is  quite  probable  that  other 
conditions  than  tuberculosis  will  give  rise  to  peribronchial  thickening. 
Thus  chronic  bronchitis,  asthma,  and  any  disease  which  leads  to  chronic 
irritation  of  these  parts,  may  cause  an  increased  formation  of  fibrous  tissue 
around  the  bronchi ;  the  repeated  inhalation  of  dust  and  smoke,  which  is  a 
concomitant  of  dwelling  in  towns,  might  quite  easily  cause  a  peribronchial 
thickening.  These  peribronchial  shadows  are  frequently  present  in  the 
chests  of  patients  who  are  suffering  from  cancer,  but  it  would  be  absurd  to 
argue  that  in  every  case  these  increased  shadows  indicated  the  presence  of 
a  peribronchial  invasion  by  cancer  cells.  Nor  would  it  be  reasonable  to 
assume  that  the  victims  of  cancer  were  also  afilicted  with  tuberculosis. 

The  appearance  of  the  chest  shadows  in  many  patients  known  to  have 
cancer  is  strongly  suggestive  of  peribronchial  phthisis.  It  must  be  borne  in 
mind  that  both  diseases  may  be  present  in  the  same  patient.  It  is  quite 
possible  that  some  of  the  patients  may  have  had  phthisis  in  early  life,  and 
what  we  see  later  are  changes  caused  by  the  healing  in  the  lung  tissue.  In 
the  opinion  of  the  writer  there  is  undoubtedly  a  large  number  of  cases, 
especially  among  patients  at  middle  life  or  later,  where  the  excess  of  fibrous 
tissue  leads  to  very  definite  peribronchial  shadows,  which  are  due  entirely 
to  the  thickening  around  the  bronchi,  and  are  diagnostic  neither  of  tubercu- 


202  RADIOGRAPHY 

losis  nor  cancer.  In  many  of  these  cases  the  thickening  of  the  bronchus 
may  be  seen  on  cross-section.  It  frequently  happens,  especially  on  the 
right  side  of  the  chest,  that  one  or  more  nearly  circular  rings  are  shown. 
These  are  caused  by  a  cross-section  of  the  bronchus,  where  it  bends  nearly 
at  right  angles  on  its  way  to  the  deeper  part  of  the  lung. 

The  radiograph  facing  page  201  well  illustrates  the  peribronchial  thicken- 
ing; it  is  from  a  case  of  malignant  disease  (Plate  XXXVII.,  Fig.  b),  the 
branching  of  the  bronchi  being  very  well  seen.  The  patient  did  not  suffer 
from  phthisis,  nor  had  she  any  secondary  deposits  of  cancer  at  the  roots  of 
the  lungs.  The  grosser  manifestations  of  tuberculosis  of  the  lung  require 
no  lengthy  description.  A  few  radiographs  will  illustrate  the  appearances 
met  with. 

Cavities  may  readily  be  shown,  especially  when  they  are  large  and 
contain  air,  though  the  localisation  of  a  small  cavity  in  an  area  of  consolida- 
tion is  not  always  possible. 

It  must  be  borne  in  mind  that  other  conditions  than  tuberculosis  give 
rise  to  appearances  identical  in  every  respect.  Actinomycosis  of  the  lung 
in  the  earlier  stages  is  practically  indistinguishable  from  a  widespread  tuber- 
culous infection.  In  the  later  stages,  however,  more  marked  changes  in  the 
former  might  lead  to  a  correct  diagnosis.  The  nodules  tend  to  become 
coarser  than  in  miliary  tuberculosis,  and  the  tendency  to  suppurate  should 
put  us  on  guard  when  examining  a  suspicious  case.  It  should  also  be  noted 
that  in  actinomycosis  the  tendency  is  for  the  disease  to  spread  and  involve  the 
pleura,  while  localised  abscesses  of  the  chest  wall  would  also  occasionally  occur. 

The  early  stages  of  a  sarcoma,  when  widely  spread  through  the  lung 
substance,  might  readily  be  mistaken  for  a  miliary  tuberculosis,  but  even  in 
these  early  stages  the  occurrence  of  a  rise  of  temperature  in  tubercu- 
losis should  be  sufficient  to  lead  to  a  correct  diagnosis.  In  the  later  stages 
the  small  centres  of  growth  rapidly  increase  in  size,  and  appear  to  be  much 
larger  and  coarser  in  structure  than  in  tuberculosis.  The  history  of  the 
patient  is  also  a  help,  as  is  also  the  presence  of  a  primary  lesion  in  other 
parts  of  the  body. 

Plate  XXXII. ,  Fig.  a  illustrates  the  mediastinal  glands  and  lung  sub- 
stance in  a  boy  aged  six,  who  two  years  before  had  had  his  arm  removed 
on  account  of  a  primary  growth  in  the  humerus.  The  secondary  exten- 
sion can  be  well  seen  in  the  glands  and  lung  substance.  The  primary 
growth  of  the  humerus  is  seen  in  Plate  XXX.,  Fig.  a. 

Syphilis. — Syphilis  of  the  lung  or  bronchi  may  cause  some  difficulty  in 
diagnosis,  especially  if  there  be  a  tendency  to  the  formation  of  gummata, 
which  might  be  mistaken  for  new  growth  or  deposits  of  tubercle.  The 
history  of  the  case  and  a  positive  Wassermann  reaction  should  clear  up  the 
diagnosis. 

Pneumonia. — Acute  lobar  pneumonia,  when  well  defined,  is  character- 
ised by  a  large,  comparatively  dense  shadow,  occupying  the  portion  of  the  lung 
involved.  It  may  be  quite  localised  to  one  lobe,  or  may  involve  the  whole 
of  one  lung,  while  the  other  lung  may  show  signs  of  congestion.     It  may  be 


PLATE  XXXVIII. — Chest  showing  Chronic  Pleurisy  with  Bi-lateral  Effusion. 
( From  the  same  patient  at  several  months'  interval. ) 

«,  Thorax  taken  with  plate  on  anterior  aspect. 
h,  Plate  on  posterior  aspect.      Shading  at  bases  indicates  involvement  of  pleura  by  carcinoma. 

c,  Double  i^leural  effusion. 
The  patient  had  been  operated  upon  for  carcinoma  of  the  breast,  and  died  with  signs  of  secondary  dei:)0sits 

in  the  lungs  and  pleura. 


INTERSTITIAL  PNEUMONIA  203 

accompanied  by  a  pleural  effusion.  The  clinical  history  and  the  feverish 
state  of  the  patient  should  give  a  clue  to  the  nature  of  the  disease,  and  the 
subsequent  resolution  of  the  inflammatory  process,  with  the  slow  subsidence 
of  th6  shadow  seen  on  radiographic  examination,  will  help  to  clear  up  the 
diagnosis.  An  acute  pneumonia  may,  however,  not  resolve  quickly,  and 
a  shadow  in  the  substance  of  the  lung  may  be  visible  for  several  weeks  after 
the  inflammatory  symptoms  have  subsided.  Later  on  the  affected  portion 
of  lung  may  become  fibrosed.  It  is  this  class  of  case  which  gives  rise  to 
great  difficulty  in  radiographic  diagnosis.  Acute  broncho-pneumonia,  when 
occurring  in  children,  is  another  condition  which  leads  to  great  difficulty  in 
diagnosis,  especially  as  an  acute  miliary  tuberculosis  gives  nearly  the  same 
appearances  on  radiographic  investigation. 

Interstitial  Pneumonia. — The  forms  of  interstitial  pneumonia  which 
result  in  an  increase  of  the  fibrous  tissue  of  the  bronchi  and  lungs  may  also 
give  rise  to  difficulties  of  diagnosis.  The  most  commonly  met  with  are  : 
(1)  Those  following  an  acute  pneumonia  ;  (2)  those  due  to  inhalation  of  dust ; 
(3)  those  due  to  the  chronic  action  of  bacterial  poisons,  e.g.  tuberculosis, 
syphilis,  actinomycosis. 

Pneumokoniosis. — Interstitial  pneumonia  due  to  the  inhalation  of 
dust.  There  are  three  varieties  of  this  according  to  the  type  of  dust  inhaled  : 
(1)  Anthrocosis,  coal-miners'  lung;  (2)  silicosis,  stone-masons'  lung;  (3) 
siderosis,  needle-grinders'  lung.  In  all  these  forms  the  foreign  particles 
are  inhaled  and  absorbed  by  the  lymphocytes.  They  are  deposited  along  the 
course  of  the  lymphatics,  forming  nodules,  and  tending  by  chronic  irritation 
to  a  marked  degree  of  fibrosis.  The  lymph-glands  are  enlarged  and  indurated. 
In  all  these  types  the  distinguishing  feature,  in  contradistinction  to  that  of 
malignant  disease,  is  the  more  uniform  distribution  of  patches  of  induration 
all  over  the  lung  and  bronchial  tracts. 

Abscess  of  the  Lung". — Abscess  of  the  lung  is  occasionally  met  with, 
an  area  of  consolidated  lung  tissue  surrounding  a  central  opacity.  Radio- 
graphically,  the  appearances  may  simulate  new  growth,  and  an  exploratory 
operation  may  be  the  only  definite  w^ay  of  establishing  a  correct  diagnosis. 

Bronchiectasis. — ^This  condition  may  be  found  in  patients  also  sufier- 
ing  from  chronic  bronchitis  and  tubercular  and  malignant  disease.  A 
marked  degree  of  dilatation  and  peribronchial  thickening  may  cause  shadows 
which  are  sometimes  indistinguishable  from  those  caused  by  a  localised  new 
growth. 

Differential  Diagnosis  in  Diseases  of  the  Pleura.— Acute  pleurisy 
is  frequently  characterised  by  an  effusion  of  serum  into  the  pleural  cavity. 

Serous  pleural  effusion  is  readily  recognised.  It  may  obscure  the  whole 
of  the  lung  shadow,  or  the  lung  may  be  pushed  upward  and  inward  towards 
the  middle  line. 

Chronic  Pleurisy.— When  this  involves  the  parietal  and  visceral  layers 
considerable  thickening  of  the  pleura  may  ensue,  and  this  may  lead  to  a 
degree  of  compression  of  the  lung  which  may  give  the  impression  of  a 
malignant  growth. 


204  KADIOGRAPHY 

Secondary  cancerous  deposits  must  also  be  looked  for.  The  pleura  is 
most  frequently  involved  in  these  cases,  thickening  at  the  bases  with  or 
without  an  effusion  being  frequently  met  with,  or  the  growth  may  extend 
outward  to  the  lung  substance.  The  earliest  manifestation  of  a  recurrence 
of  cancer  may  be  found  in  the  pleura  ;  the  mode  of  invasion  is  described  on 
p.  196.  Radiographically,  the  recurrence  may  be  shown  as  fine  irregular 
opacities  on  the  inner  surface  of  a  rib,  and  spreading  along  the  pleura  cover- 
ing the  rib,  involving  also  the  pleura  covering  the  intercostal  muscles.  The 
shadow  may  show  merely  an  increase  in  striation  of  the  pleura,  or  it  may 
appear  as  comparatively  dense  plaques.  The  mediastinal  glands  may  be  in- 
volved, being  seen  at  the  hilus  of  one  or  both  lungs,  where  discrete  glands  may 
be  demonstrated.  The  anterior  mediastinum  is  occasionally  involved,  and  in 
order  to  show  these  deposits  it  is  necessary  to  take  an  oblique  lateral  view, 
when  the  enlarged  glands  may  be  seen  just  behind  the  sternum.  Glands  in 
the  axilla  and  in  the  supraclavicular  areas  may  also  be  met  with,  and  should 
be  shown  on  radiographic  examination. 

Purulent  Effusion,  Empyema. — This  may  readily  be  recognised.  The 
shadow  is  very  dense,  and  limited  more  or  less  according  to  the  amount  of 
pus  present.  Localised  empyema  may  give  appearances  of  a  like  nature, 
especially  when  the  process  is  interlobar.  Empyema  which  has  been  drained 
and  followed  by  collapse  of  the  lung  is  another  condition  which  must  be 
considered.  The  presence  of  an  opening  into  the  pleural  sac  will  be  a  guide 
as  to  the  nature  of  the  case,  but  when  a  doubt  exists,  the  cavity  may  be 
injected  with  bismuth  emulsion  and  its  exact  size  determined. 

Abscess  of  the  Lung  is  sometimes  met  with  apart  from  an  empyema. 
It  may  be  deep-seated  and  very  difficult  to  determine. 

Pyo-pneumo  Thorax.- — Pus  is  present  in  the  lower  part  of  the  pleural  sac. 
A  clear  area  is  seen  above  the  level  line  of  pus,  and  lung  tissue  above  the 
clear  space. 

Foreign  Bodies  in  the  Pleural  Cavity. — Occasionally  a  drainage  tube  gets 
into  the  pleural  cavity  after  an  operation  for  draining  the  pleura.  This  can 
readily  be  located.  Efforts  for  removal  may  be  facilitated  by  a  screen 
examination,  and  the  forceps  guided  to  the  tube. 

Irreg-ularities  in  the  Outline  of  the  Diaphragm,  to  whatever 
cause  they  may  be  due,  will  often  give  appearances  which  lead  to  difficulties 
in  diagnosis  ;  moreover,  a  secondary  involvement  of  the  liver  is  not  at  all 
uncommon  in  cases  where  a  growth  in  the  lung  exists. 

Tumours  of  the  chest  ivall  may  also  have  to  be  excluded. 

Hydatid  cyst,  though  not  common  in  this  country,  must  not  be  over- 
looked. The  appearance  of  such  a  cyst  is  diagnostic,  and  a  rounded,  sharply- 
cut  shadow  in  any  part  of  the  lungs  should  excite  suspicion  of  hydatid 
disease.  Cysts  may  arise  from  any  of  the  structures  composing  the  walls, 
i.e.  sternum,  ribs,  costal  cartilages,  or  spine.  The  appearances  presented 
by  a  case  of  primary  sarcoma  arising  from  the  inner  aspect  of  a  rib  are  typical 
of  cyst — a  rapidly  growing  sarcoma,  which  becomes  haemorrhagic,  the  walls 
of  the  growth  consist  of  thickened  pleura,  and  the  cavity  is  filled  with 


PLATE  XXXIX.— Chests. 


a,  The  arch  of  the  iliapliragm  on  the  left  side  is  high,  the  clear  area  is  caused  by  gas  in  a  distended 
■stomacli.      Note  fluid  level  at  the  lower  limit  of  the  clear  area. 

h,  Extensive  distribution  of  calcareous  glands  in  thorax,  axillae,  and  cervical  regions.  Healed  tubercu- 
losis of  many  years'  standing. 

c,  Calcified  glands  at  roots  of  Ijoth  lungs.     Healed  tuberculosis. 


EXAMINATION  OF  THE  HEART  AND  AORTA  205 

blood-clot  and  growth.    The  X-ray  appearances  will  show  it  to  have  a  well- 
defined  wall  with  semi-fluid  contents. 


The  Examination  of  the  Heart  and  Aorta 

Variations  in  the  Size,  Shape,  and  Position  of  the  Heart.— The 

heart  may  be  greatly  enlarged  in  all  directions,  or  it  may  show  a  marked 
hypertrophy  of  the  left  ventricle.  Dilation  of  the  right  side  of  the  heart 
may  be  distinguished  from  hypertrophy  by  the  lack  of  density  in  the  shadows. 

The  heart  may  be  displaced  to  one  or  other  side.  It  is  sometimes  seen 
on  the  right  side  of  the  thorax,  the  aorta  in  such  a  case  bearing  down  to  the 
right  of  the  middle  line. 

The  radiographic  appearances  of  hydropericardium  are  characteristic. 
The  cardiac  outline  is  greatly  enlarged  in  all  directions,  and  there  is  a  marked 
increase  in  the  breadth  of  the  shadow.  It  is  bulged  out,  and  gradually 
lessens  in  size  towards  the  base  of  the  heart,  the  shadow  appearing  to  be 
widened  at  the  apex  where  the  heart  rests  upon  the  diaphragm.  The  outline 
of  the  heart  may  be  faintly  seen  through  the  shadow  caused  by  the  dilated 
pericardium.  The  usual  pulsation  of  the  heart  is  lost  or  only  seen  faintly 
at  the  apex. 

There  are  many  variations  in  the  appearance  of  the  heart-shadow  which 
have  a  definite  significance  in  diagnosis.  The  small  "  nervous  "  heart  of  the 
neurotic  patient  is  characteristic.  In  thin  patients  the  contractions  of  the 
heart  can  be  plainly  seen,  while  in  some  instances,  where  there  is  irregularity 
in  the  heart-beat,  the  intermissions  may  be  observed  on  the  fluorescent 
screen.  Similarly,  in  cases  of  Stokes- Adams  disease,  where  there  is  a  slowing 
of  the  pulse  with  alterations  in  the  cardiac  rhythm,  these  phenomena  may 
readily  be  seen  on  the  screen.  The  vertical  heart  seen  in  many  cases  of 
tubercle  of  the  lungs  is  also  a  recognised  feature  in  the  radiography  of  the 
thorax.  The  heart  may  be  enlarged  irregularly  in  syphilis,  gummata  may 
cause  shadows  which  might  be  mistaken  for  other  conditions,  and  aneurism 
of  the  heart  may  cause  an  irregular  shadow  indistinguishable  from  gumma 
or  new  growth.  The  heart  may  also  be  the  seat  of  a  malignant  neoplasm 
whichj  may  be  primary  or  secondary  to  a  lesion  on  the  lungs,  pleura,  or 
mediastinum. 

Cysts  in  the  heart  are  rare,  but  the  possibility  of  their  occurrence  should 
be  kept  in  mind  when  an  abnormal  shadow  is  seen  on  the  cardiac  area. 
Hydatid  cyst  is  extremely  rare  in  this  situation. 

Screen  examination  of  the  heart  is  often  very  serviceable  in  diagnosis  ; 
the  organ  may  be  seen  pulsating  and  the  phases  of  the  cardiac  cycle  studied. 

Thoracic  Aneurism.— The  screen  examination  is  very  important, 
and  should  be  employed  in  every  patient  sent  for  diagnosis.  A  radiograph 
is  necessary  also,  but  in  this,  as  in  all  thoracic  examinations,  it  must  be 
insisted  upon  that  the  plate  is  merely  a  permanent  record  of  what  we  see 
on  the  screen,  and  only  a  phase  of  what  can  be  seen  when  a  thorough 
screening  is  carried  out. 


206 


EADIOGEAPHY 


The  patient  must  be  examined  in  at  least  three  positions  :  (1)  antero- 
posterior ;  (2)  postero-anterior  ;  (3)  right  lateral  oblique,  in  which  the 
patient  faces  the  screen,  and  turns  half  round  towards  his  right.  In  the 
first  two  positions  the  heart  is  well  seen,  but  the  normal  aorta  is  almost 
entirely  masked  by  the  central  opacity  formed  by  the  spine  behind  and  the 

sternum  in  front,  with  the  excep- 
I  tion  of  the  left  lateral  aortic  bulge, 

which  is  not  evident  in  all  cases. 

In  the  case  of  aortic  aneurisms 
there  will  be  seen  shadows  of  vary- 
ing density  and  size,  projecting  to 


Fig.  156. — Position  of  thorax  for  lateral  oblique 
position,  to  show  position  of  plate  and  source  of 
X-rays.  This  is  a  useful  position  for  the  examina- 
tion of  the  aorta,  oesophagus,  and  mediastinum. 


Fig.  157. — Diagram  to  illustrate 
the  appearance  of  thorax  in 
semi-lateral  position. 

the  right  or  left  of  the  central 
shadow,  limited  by  rounded, 
sharply-defined,  and  often  pulsating 
borders.  The  direction  which  the 
bulge  takes  may  give  an  indication 
of  the  position  of  the  aneurism.  A 
shadow  projecting  to  the  right  and 
lying  nearer  to  the  front  than  the  back  indicates  an  aneurism  of  the  ascend- 
ing aorta,  whereas  a  similar  bulge  to  the  left,  and  lying  nearer  the  back 
than  the  front,  indicates  the  presence  of  an  aneurism  of  the  descending 
aorta. 

There  are  other  methods  of  detecting  the  position  and  origin  of  an  aortic 
aneurism  : 

(1)  The  tube  may  be  moved  from  side  to  side  or  up  and  down. 

(2)  The  patient  may  be  rotated,  and  observations  made  of  the  change 
in  shape  of  the  shadows  as  the  patient  moves.  The  size  of  the  shadow  as 
seen  in  the  ordinary  methods  of  examination  is  misleading,  the  distortion 
caused  by  the  nearness  of  the  tube  to  the  patient  making  the  resulting 
shadows  appear  larger  than  they  really  are,  the  distortion  being  equal  on 
all  the  structures  recorded  on  the  plate. 

If  the  exact  size  of  the  organs  is  required,  then  we  must  use  orthodia- 
graphy or  tele-r5ntgenography.     The  former  consists  of  an  accurate  drawing 


PLATE  XL. — Chests  showing  Aneurism  and  New  Growth. 


a,  Aneurism  of  descending  aorta,  lateraL 

6,  Same  case  antero-posterior  position. 

c,  Secondary  growth  in  mediastinum,  simulating  aneurism. 


AORTIC  ANEURISM 


207 


of  the  size  of  the  heart  and  aOrta  on  a  paper  in  front  of  or  behind  the  patient, 
a  somewhat  complicated  mechanical  device  being  necessary.  This  method  is 
very  rarely  used  in  this  country,  though  it  has  been  extensively  used  by 


\     /'   / 


/             1  ^l 

1 

7  8  9  10 

■    FiQ.  158. Diagrams  to  illustrate  points  of  difference  between  dilated  aorta  and  aneurisms 

(after  Holzknecht). 

1.  Normal  heart  and  aorta  seen  from  the  front. 

2.  Normal  heart  and  aorta,  lateral  oblique  view. 

3.  Normal  aorta  in  antero-posterior  position. 

4.  Normal  aorta  in  lateral  position. 

5  and  6.  Appearances  seen  in  dilated  aorta.  Antero-posterior  anil  lateral  positions. 
7  and  8.  The  appearance  seen  in  aneurism.  Antero-posterior  and  lateral  positions. 
9  and  10.   A  small  aneurism  arising  from  the  under  aspect  of  the  arch. 

continental  workers,  notably  by  Groedal  of  Mannheim,  who  gives  many 
interesting  diagrams  of  typical  cardiac  conditions.  He  differentiates 
between  the  cardiac  outlines  in  various  forms  of  cardiac  disorder,  such  as 
mitral  stenosis,  aortic  insufficiency,  etc. 


208  EADIOGRAPHY 

Tele-rontgenographj  consists  of  making  pictures  at  a  considerable 
distance  from  the  anti-cathode  of  the  tube.  When  the  distance  is  from 
6  to  6|  feet  the  size  of  the  shadows  practically  approaches  the  actual  size  of 
the  organs.  To  obtain  good  pictures  the  exposure  must  be  rapid,  and  this 
can  only  be  obtained  when  a  powerful  installation  is  used. 

The  presence  of  pulsation  must  be  carefully  looked  for.  When  found 
it  is  often  difficult  to  determine  whether  it  is  caused  by  the  pulsation  of  the 
aorta,  or  is  the  normal,  or  that  communicated  through  a  tumour  in  the 
mediastinum. 

The  most  important  position  for  the  determination  of  aneurism  of  the 
aorta  is  the  right  lateral  oblique,  first  described  by  Holzknecht  in  1901,  By 
its  means  we  are  able  to  demonstrate  nearly  all  aneurisms;  but  the  great  value 
of  the  method  lies  in  the  demonstration  of  quite  small  aneurisms,  which  in 
the  other  positions  are  masked  by  the  central  opacity.  To  assume  this 
position  the  patient  stands  with  his  back  to  the  tube  and  his  face  to  the 
screen  or  plate,  and  turns  half  round  towards  his  right  side,  holding  his  arms 
above  his  head. 

The  important  points  to  determine  and  to  differentiate  must  be  borne 
in  mind.  A  dilated  aorta  will  simulate  an  aneurism  on  the  screen.  It 
pulsates,  and  there  is  a  widening  of  the  aortic  shadow.  The  normal  aorta  in 
a  number  of  cases  shows  at  the  arch  a  distinct  bulge  to  the  left,  which  must 
not  be  mistaken  for  an  aneurism. 


THE  X-RAY  EXAMINATION  OF  THE  ALIMENTARY 

SYSTEM 

The  routine  examination  of  the  alimentary  system  is  one  of  growing 
importance  to  the  radiologist.  So  much  can  be  ascertained  by  a  thorough 
examination  with  the  aid  of  the  opaque  meal  that  a  lengthy  description  is 
necessary.  ' 

Methods  of  Examination. — (1)  Radioscopy  by  means  of  the  fluorescent 
screen.  (2)  Radiography  by  the  action  of  X-rays  upon  photographic  plates, 
a  comparison  being  made  of  plates  taken  at  intervals.  Both  methods  are 
extremely  useful,  and  neither  can  be  dispensed  with  if  a  thorough  examina- 
tion and  record  of  observations  made  are  necessary  for  the  completion  of  the 
investigation  of  any  particular  case.  By  these  methods  many  observations 
of  value  may  be  made.  The  localisation  of  a  foreign  body  becomes  easy, 
while  strictures  in  the  oesophagus,  and  diseases  of  the  stomach  and  bowels 
are  now  daily  subjects  for  Rontgen  examination. 

The  Examination  of  the  (Esophagus 

The  presence  of  diverticula  of  the  oesophagus  can  readily  be  shown  by 
the  use  of  a  quantity  of  bismuth  emulsion  and  subsequent  examination  by 
screen  and  plates.  The  substances  most  commonly  used  are  bismuth  in  the 
shape  of  (1)  Cachet;  (2)  Emulsion;  (3)  In  food,  e.g.  sugar  of  milk,  bread- 
crumbs, porridge,  etc.  The  cachet  is  open  to  the  objection  that  unless  it 
is  very  small  it  is  apt  to  be  arrested  in  a  normal  oesophagus.  The  best 
medium  to  employ  is  the  emulsion,  which  may  be  of  a  fairly  thick  consistence. 
-  The  oesophagus  may  be  examined  in  two  positions  : 

1.  The  Anterior,  when  shadows  of  tumours  may  sometimes  be  shown. 

2.  The  Right  Antero-lateral. — This  is  the  important  position.  The 
patient  stands  upright  with  the  tube  behind,  and  the  fluorescent  screen  placed 
in  front.  The  patient  is  then  adjusted  so  that  the  position  of  the  spine 
relative  to  the  heart  and  aorta  gives  the  maximum  clear  space  between  the 
two,  this  clear  space  containing  the  oesophagus.  A  little  practice  enables 
the  operator  to  get  the  best  position.  The  patient  is  told  to  swallow  some 
bismuth  food,  and  the  operator  keeps  a  careful  watch  for  its  passage  down  the 
oesophagus,  this  being  indicated  by  a  dark  rapidly  moving  shadow  passing 
down  the  oesophagus  to  enter  the  stomach.     Any  delay  in  transit  should  be 

209  14 


210 


EABIOGRAPHY 


carefully  noted.     By  this  metliod  of  examination  it  is  possible  accurately 
to  locate  stricture  of  the  oesophagus  or  obstruction  at  the  cardiac  end  of  the 


Vertebra 


Heart 


Sternum 


Fig.  159. — Diagram  to  show  the  position  for  lateral  oblique  examination  of  the  thorax,  and  the 
path  of  the  raj's  from  tube  to  plate. 

stomach.     Foreign  bodies  jmay  readily  be  detected  in  the  oesophagus  and 
accurately  located. 


Examination  of  the  Stomach 

The  examination  of  the  stomach  and  intestinal  canal  has  become  one 
of  the  most  important  spheres  of  radiographic  work.  Its  value  in  diagnosis 
is  very  great,  but  much  remains  to  be  done  before  a  claim  can  be  laid  to 
expert  knowledge  in  the  interpretation  of  the  results  obtained.  Even  now, 
when  the  method  has  become  general,  authorities  are  found  to  hold  con- 
flicting views  on  the  interpretation  of  the  results.  The  technique  followed 
by  the  observers  differs  in  many  respects,  and  this,  no  doubt,  to  some  extent 
accoimts  for  the  conflicting  opinions.  In  spite  of  the  great  difficulty  in  the 
way  of  correct  interpretation,  it  is  satisfactory  to  know  that  by  means  of 
X-ray  examination  it  is  possible  to  ascertain  much  about  the  position,  size, 
and  movements  of  the  stomach,  the  process  of  digestion,  and  departures 
from  the  normal. 

At  the  meeting  of  the  Electro-therapeutic  Section  of  the  British  Medical 
Association,  held  in  Liverpool  in  1912,  a  joint  discussion  took  place  with  the 


PLATE  XLI. — Chest  showing  Djlatation  of  (Esophagus. 

a,  (Esophagus  dilated  and  filled  with  food. 

h,  (Esophagus  empty  after  an  interval  of  3  days,  showing  irregular  shading  in  mediastinum, 
c,   Lower  portion  of  dilated  oesophagus  containing  bismuth  food  ;  point  of  stricture  is  seen,  and  food  which 
has  passed  into  the  stomach.  ; 


ANATOMY  OF  THE  STOMA r"H 


211 


Anatomical  Section  on  the  normal  stomacli.  It  was  almost  unanimously 
agreed  that  radiography  had  modified  the  opinioi  held  formerly  as  to  the 
position  of  the  normal  stomach. 
Hertz  describes  three  positions 
of  the  stomach  :  (1)  When  one- 
third  full ;  (2)  when  half  full  ; 
(3)  when  fully  distended. 

The  following  is  quoted  from 
Hertz's  paper  : 


Anatomy  of  the  Stomach 


spine 


Diaphragm 

Fig.  IGO.  —  Diagrammatic  repre- 
sentation of  tlie  lateral  view  of 
thorax. 


The  Subdivisions  of  the  Stomach. — ■ 
The  oesophagus  enters  the  stomach 
very  obliquely,  the  acute  angle  it 

forms  being  called  the  incisura  cardiaca.  The  cardiac  orifice,  though  not 
surrounded  by  a  definite  sphincter,  has  a  much  smaller  diameter  than  the 
lower  extremity  of  the  oesophagus,  as  great  a  period  being  consequently  required 
for  the  passage  of  a  mouthful  of  food  through  the  cardia  as  for  its  passage 
down  the  whole  length  of  the  oesophagus. 

The  stomach  can  be  divided  into  a  larger  cardiac  part  and  a  smaller  pyloric 

part.  The  cardiac  part  consists  of  the  fundus 
and  body,  the  fundus  being  the  segment  of 
the  stomach  which  lies  above  a  horizontal 


Fig.  161. — The  appearances  seen  on 
the    fluorescent   screen    after   the 

.  patient  has  taken  bismuth  food 
are  shown  diagranimatically.  The 
shadows  represent  the  passage  of 
a  number  of  mouthfuls  of  food 
down  the  oesophagus ;  when  a 
large  quantity  is  swallowed  in 
successive  acts  of  deglutition,  a 
continuous  line  of  dark  shadow  is 
seen.  This  may  be  seen  to  vary 
in  diameter,  corresponding  with 
the  contractile  movements  of  the 
oesophagus. 


Fig.  162. — Diagram  to  illustrate  the  appear- 
ance seen  in  a  semi-lateral  view  of  the 
thorax.  The  dark  shadow  at  the  top  is 
caused  by  bismuth  food  in  a  dilated 
oesophagus.  The  point  of  stricture  is 
seen  at  the  lower  extremity  of  the  dark 
shadow. 


plane  passing  through  the  cardiac  orifice.  The  body  is  situated  enthely  to  the 
left  of  the  middle  line.  In  the  erect  position  it  is  either  vertical,  or,  especially 
in  men,  shghtly  inclined  towards  the  right ;    in   the   recumbent   position  it 


211 


RADIOGRAPHY 


Fig.  163. — Diagram  from  a  text-book 
of  anatomy  showing  position  of 
stomach.  (Hertz.) 
This  shows  what  was  supposed  to  be 
the  shape  and  position  of  the  stomach 
before  the  radiographic  method  of  in- 
vestigation was  introduced.  It  is  worthy 
of  note,  however,  that  some  anatomical 
writers  described  a  different  shape  and 
position.  The  Edinburgh  Stereoscopic 
Atlas  of  Anatomy  illustrates  a  stomach 
which  for  shape  and  position  might 
easily  be  an  exact  reproduction  of  the 
normal  stomach  as  demonstrated  by  the 
radiographic  method. 


is  always  rather   more   oblique.      Its  axis  is   inclined  forwards  as  it  passes 
downwards. 

The  incisura  angularis^  a  well-marked  depression  on  the  lesser  curvature, 
most  obvious  in  the  erect  position,  separates  the  body  from  the  pyloric  part  of 
the  stomach,  but  there  is  no  definite  depression  on  the  greater  curvature  marking 

the  separation.  The  pyloric  part  of  the 
stomach  consists  of  the  pyloric  vestibule  and 
pyloric  canal,  the  termination  of  which  is  the 
pylorus.  The  pyloric  vestibule  is  directed 
upwards  and  slightly  backwards  as  it  turns 
towards  the  right ;  it  generally  reaches  just 
beyond  the  middle  line.  The  pyloric  canal  is 
about  3  cm.  in  length  ;  it  is  directed  more 
definitely  backwards  than  the  pyloric  vestibule, 
but  is  inclined  slightly  upwards  and  to  the 
right.  Its  termination  projects  into  the 
duodenum,  producing  a  striking  resemblance 
to  the  portio  vaginalis  of  the  cervix  uteri. 

The  position  of  the  pylorus  is  only 
occasionally  marked  by  a  slight  constriction 
on  its  outer  aspect ;  it  can  be  more  readily 
recognised  by  a  venous  ring,  the  position  of 
which  corresponds  closely  with  it.  Both  the 
circular  and  longitudinal  muscular  coats  are 
much  thicker  round  the  canal  than  in  the  rest 
of  the  stomach.  The  circular  fibres  are  dis- 
posed in  the  form  of  a  sphincter,  which 
attains  its  greatest  development  at  the  duodeno-pyloric  junction,  where  it  is 
separated  by  a  connective  tissue  septum  from  the  circular  coat  of  the  duodenum. 
Only  a  few  of  the  longitudinal  more  superficial  fibres  are  continuous  with 
those  of  the  duodenum,  the  majority  form- 
ing distinct  fasciculi,  which  penetrate  the 
substance  of  the  sphincter,  in  which  some 
end,  whilst  others  reach  the  submucous 
tissue. 

The  Empty  Stomach. — In  the  empty  con- 
dition the  upper  third  of  the  stomach  is  pear- 
shaped  and  contains  gas.  The  rest  of  the  organ 
passes  to  the  pylorus  in  the  form  of  a  collapsed 
tube.  The  pylorus  is  situated  in  the  transpyloric 
plane,  midway  between  the  upper  margin  of  the 
manubrium  sterni  and  the  upper  margin  of  the 
symphysis  pubis  in  the  middle  line,  or  very 
slightly  to  the  right.  The  greater  curvature 
in  the  erect  position  reaches  the  level  of  the 
umbilicus  or  slightly  above  it.  In  the  hori- 
zontal position  the  stomach  lies  more  obliquely,  and  the  greater  curvature 
scarcely  reaches  below  the  pylorus. 

The  Half-filled  Stomach. — When  the  stomach  is  partially  filled  by  a  standard 
bismuth  meal,  half  a  pint  in  volume,  its  body  is  almost  uniform  in  diameter,  and 
its  axis  corresponds  in  position  with  that  of  the  empty  organ.  As  the  diameter 
of  the  fundus  is  rather  greater  than  that  of  the  body,  a  slight  constriction  marks 
the  separation  between  the  two  parts  of  the  stomach.     The  diameter  of  the 


Fig.  164. — The  position  of  the  empty 
stomach.  Diagrammatic  representa- 
tion of  the  screen  examination. 
(Hertz.) 


PLATE  XLII. — Stomach  showing  Pyloric  Stenosis. 


a,  Marked  delay  in  emptying  caused  by  cicatricial  contraction  resulting  from  healed  gastric  ulcer. 

h,  Four  hours  after — food  taken.      Shows  food  passing  along  duodenum. 

c,  Eight  hours  after — food  still  in  stomach.     The  organ  is  not  now  contracting  well. 


POSITION  OF  THE  STOMACH 


213 


pyloric  vestibule  becomes  slightly  smaller  as  it  approaches  the  pyloric  canal. 
The  pyloric  canal  is  always  closed,  except  when  chyme  is  passing  through  it  into 
the  duodenum,  although  its  cavity  is  generally  more  or  less  expanded  in  post- 
mortem specimens.  Even  when  the  sphincter  is  lelaxed  for  the  passage  of  food, 
the  canal  is  so  narrow  that  nothing  more  than  a  very  fine  line  can  be  seen  with  the 
X-rays,  joining  the  gastric  and  duodenal  shadows.  In  the  vertical  position  the 
greater  curvature  almost  always  reaches  below  the  umbilicus,  the  average  dis- 
tance being  2|-  cm.  in  men  and  5  cm.  in  women.  In  the  horizontal  position  the 
greater  curvature  is  on  an  average  6  cm.  higher,  its  lowest  point  being  conse- 


c n 


f 

Fig.  165.— Diagrams  showing  stages  of  filling  of  stomach  by  opaque  meal.     (After  Hertz.) 
(a)  Stomach  as  seen  after  a  bismuth  meal  showing  depressions  produced  by  peristaltic  waves. 
(6)  Half-filled  stomach  in  vertical  position,  depressions  caused  by  peristaltic  waves  not  shown, 
(c)  Filled  stomach  in  horizontal  position  as  seen  with  the  X-rays. 
{d)  Half-filled  stomach  in  horizontal  position  as  seen  with  the  X-rays. 
-(e)  Filled  stomach  in  vertical  position  as  seen  with  the  X-rays. 

(/)  Superimposed  outlines  of  empty,  half-filled,  and  full  stomach  as  seen  with  the  X-rays  in  the 
vertical  position. 

quently  above  the  umbilicus.  The  junction  between  the  horizontal  and  de- 
scending portions  of  the  duodenum  is  fixed,  but  the  pylorus  is  mobile,  and  in  the 
half-filled  stomach  it  is  situated  distinctly  lower  in  the  erect  than  in  the  recumbent 
position.  The  fundus  does  not  drop  from  the  diaphragm  when  the  erect  position 
is  assumed,  but,  as  the  diaphragm  itself  falls  slightly,  the  fundus  is  also  a  little 
lower  in  the  vertical  than  in  the  horizontal  position. 

The  Full  Stomach. — Owing  to  the  greater  resistance  of  the  structures  in 
contact  with  the  lesser  curvature  than  those  in  contact  with  the  greater  curvatm-e, 
when  the  stomach  is  filled  with  a  large  meal  its  walls  expand  more  in  the  direction 
of  the  latter  than  the  former,  so  that  its  axis  comes  to  lie  outside,  and  below 


214  EADIOGKAPHY 

that  of  tlie  empty  and  the  lialf-filled  stomacli.  The  left  dome  of  the  diaphragm 
is  pushed  upwards  until  it  reaches  as  high  as,  or  higher  than^,  the  right  dome. 
The  diameter  of  the  body  of  the  stomach  is  so  greatly  increased  that  the  con- 
striction between  it  and  the  fundus  disappears.  The  collection  of  gas — the 
"  magenblase  "  of  the  German  radiographer — is  wider  and  more  shallow  than 
that  of  the  half-empty  stomach.  The  diameter  of  the  body  is  uniform  ;  that  of 
the  pyloric  vestibule  is  almost  as  great  as  that  of  the  body,  but  it  diminishes  as 
it  approaches  the  pyloric  canal,  which  invariably  remains  closed.  The  pyloric 
vestibule  is  so  greatly  widened  that  it  reaches  considerably  beyond  the  middle 
line,  and  when  viewed  from  the  front  completely  hides  the  pyloric  canal,  which 
now  points  either  directly  backwards,  or  even  slightly  towards  the  left,  in  spite 
of  the  fact  that  the  pylorus  itself  also  moves  slightly  towards  the  right. 

The  Opaque  Meal. — The  examination  of  the  stomach  is  carried  out  by 
means  of  the  "  Bismuth  Meal,"  or,  to  use  a  more  general  term,  the  "  Opaque 
Meal." 

The  preparation  of  the  patient  prior  to  the  ingestion  of  the  bismuth  meal 
is  a  point  of  considerable  importance.  Authorities  differ  as  to  the  exact 
procedure,  and  will  probably  continue  to  do  so,  in  spite  of  efforts  to  establish 
a  standard  opaque  meal,  and  a  routine  method  of  preparation  and  examina- 
tion. While  such  widely  diverse  methods  as  those  suggested  by  Hertz, 
Morton  and  others,  and  the  special  technique  recommended  by  Jordan,  are 
used,  great  discrepancies  in  results  must  follow.  Given  the  use  of  a  standard 
opaque  meal,  a  routine  method  of  preparation,  and  a  definite  system  of  ex- 
amination, it  should  be  possible  for  individual  observers  to  establish  a  normal 
condition  of  affairs,  and  from  this  we  should  be  able  to  demonstrate  marked 
departures  from  the  normal.  In  time  the  results  of  many  observers  would 
harmonise,  and  definite  statements  could  be  made  by  comparing  a  large 
number  of  such  results. 

The  method  of  preparation  of  the  opaque  meal  described  by  Dr.  Morton, 
in  opening  a  discussion  on  the  standard  opaque  meal,  is  that  followed  by  the 
majority  of  operators.  The  average  quantity  of  bismuth  oxychloride  or 
carbonate  or  barium  sulphate  is  about  three  ounces,  the  basis  of  the  meal 
consisting  of  bread  cut  into  small  cubes,  the  diluting  medium  being  warmed 
milk  sweetened  with  sugar.  The  milk  is  poured  over  the  bread  cubes,  and 
the  whole  is  gently  mixed,  the  opaque  substance  used  being  gradually  added, 
and  the  stirring  continued  until  a  fairly  stiff  mixture  is  obtained.  The 
patient  takes  the  whole  of  this  mixture,  and  the  routine  examination  is 
proceeded  with. 

A  preliminary  examination  should  be  made  of  the  abdomen  before  the 
patient  takes  the  meal,  and  a  plate  taken  for  comparison  later  on.  By  this 
method  it  is  possible  to  eliminate  other  conditions  than  gastric  or  intestinal 
lesions.  Thus  stone  in  the  kidney  pancreas  or  gall  bladder  may  be  shown. 
Dr.  Case  of  Battle  Creek  has  obtained  a  number  of  excellent  plates  of  gall- 
stones in  the  gall  bladder  and  bile  ducts  in  the  examination  of  a  large  number 
of  stomach  cases.  The  stomach  should  be  observed  while  the  opaque  meal 
is  passing  into  it,  as  valuable  data  of  the  normal  and  abnormal  condition 
of  the  alimentary  tract  may  thus  be  obtained. 


THE  OPAQUE  MEAL  215 

Franz  Groedel  uses  40O  grammes  of  wheat-meal  porridge  with  10  per 
cent  of  bismuth  subnitrate.  This  preparation  of  bismuth,  however,  is  never 
used  now,  the  carbonate,  oxychkjride  of  bismuth,  and  more  recently  sulphate 
of  barium  being  substituted,  care  being  taken  that  the  latter  salt  is  absolutely 
pure.     He  gives  the  following  results  : 

Stomach  emptied  in  2  to  4  hours  after  the  meal. 

Small  intestine  emptied  in  a  maximum  of  4  to  5  hours  after  the  meal. 

Caecum  begins  to  fill  in  2  to  3  hours  after  the  meal. 

Csecum  filled  in  4  to  6  hours  (right  flexure). 

Transverse  colon  filled  in  4  to  12  hours  (left  flexure). 

Ampulla  of  rectum  reached  at  latest  in  24  hours. 

Rieder,  fusing  carbonate  of  bismuth  (pure),  gives  the  following  results  : 

Stomach  empty  in  3  to  3|-  hours  after  the  meal. 

Small  mtestine  begins  to  fill  in  3J  to  4  hours  after  the  meal. 

Small  intestine  empty  in  8  to  9  hours  after  the  meal. 

Hertz,  using  oxychloride  of  bismuth,  gives  the  following  results  : 

Caecum  visible  4|  hours  after  the  meal. 
Left  flexure  visible  6|  hours  after  the  meal. 
Right  flexure  visible  9  hours  after  the  meal. 
Rectum  visible  18  hours  after  the  meal. 

Groedel,  using  a  meal  composed  of  250  grammes  of  barium  sulphate, 
20  grammes  of  maize  flour,  20  grammes  of  sugar,  20  grammes  of  chocolate 
or  cocoa,  and  400  c.c.  of  water,  gives  quite  different  results  : 

Stomach  empty  in  1|^  to  2  hours  after  the  meal. 
Csecum  begins  to  fill  in  1  to  1|  hours. 
Caecum  filled  in  2  to  6  hours  (right  flexure). 
Transverse  colon  filled  in  4|-  hours  (left  flexure). 
Rectal  ampulla  reached  24  hours  at  latest. 

These  figures  show  that  with  barium  sulphate  the  stomach  empties 
itself  just  twice  as  fast  as  with  bismuth  subnitrate,  and  that  the  carbonate 
and  oxychloride  have  practically  the  same  action  as  the  subnitrate. 

'  Groedel  concludes  that  bismuth  somewhat  decreases  the  normal  motihty 
of  the  stomach,  and  he  considers  that  barium  sulphate  is  the  best  contrast 
material  for  the  Rontgen  examination  of  the  stomach,  and  that  bismuth 
leads  to  false  conclusions,  since  we  are  dealing  only  with  comparative  results. 

Corresponding  to  the  increased  motility  of  the  stomach  we  get  with 
barium  sulphate  an  increased  flow  of  well- contrasted  chyme  in  the  small 
intestine,  which  is  markedly  more  pronounced  than  after  the  bismuth  meal. 
This,  he  holds,  is  a  great  advantage  for  many  diagnostic  purposes.  The 
duodenum  and  small  intestine  are  flooded  with  opaque  chyme,  and  show  as 
ribbon-like  shadows,  almost  as  broad  as  the  large  intestine.  Other  advan- 
tages of  the  more  rapid  emptying  of  the  stomach  are  that  the  caecum  is 


216  EADIOGRAPHY 

already  visible  an  liour  to  an  hour  and  a  half  after  the  meal,  which  is  much 
earlier  than  is  the  case  with  the  ordinary  bismuth  meal,  and  that  the  small 
intestine  is  emptied,  and  the  ascending  colon  filled,  much  more  quickly. 

The  four  opaque  substances  used  have  none  of  them  any  great  influence 
on  the  motility  of  the  large  intestine,  the  time  of  evacuation  being  ap- 
proximately the  same  in  all  four  cases.  Hence  barium  sulphate  is  the  most 
suitable  opaque  substance  for  the  R5ntgen  examination  for  the  following 
reasons  : 

(1)  It  gives  sufficient  data  for  the  determination  of  the  physiological 
motility  of  the  alimentary  canal. 

(2)  It  is  much  cheaper. 

(3)  It  stimulates  the  flooding  of  the  small  intestine  with  a  well-contrast- 
ing chyme,  thus  greatly  facilitating  the  Rontgen  examination. 

(4)  The  taste  of  the  barium  porridge  is  much  pleasanter  than  that  of  any 
other  of  the  opaque  meals. 

(5)  The  use  of  the  barium  meal  is  a  saving  of  time,  since  in  consequence 
of  its  stimulating  action  the  examination  may  be  made  at  shorter  intervals. 

It  would  appear  that  none  of  these  four  substances  necessarily  gives  the 
correct  time  factors  on  which  to  base  definite  conclusions  regarding  the 
physiological  action  of  the  stomach  and  intestine,  the  bismuth  salts  appearing 
to  delay  the  motility  of  the  stomach,  while  the  barium  sulphate  stimulates 
it.  The  conclusions  we  wish  to  draw,  however,  are  comparative  only, 
therefore  it  matters  little  which  salt  is  employed  so  long  as  the  same  one  is 
used  in  all  cases. 

A  useful  routine  method,  for  the  examination  of  the  intestinal  canal, 
which  may  be  varied  to  suit  the  particular  case  and  convenience  of  the 
operator,  may  be  formulated  : 

(a)  9  A.M.  Examination  of  the  stomach  in  the  process  of  filling.  Record 
of  the  shape  and  position  of  the  full  organ.  Screen  examination  is  usually 
sufficient,  but  any  marked  departure  from  the  normal  should  be  radio- 
graphed in  order  that  a  permanent  record  may  be  obtained. 

(6)  9.15  A.M.  Examination  of  the  duodenum,  screen  and  plate  if 
necessary. 

(c)  10  A.M.  One  hour  after  the  meal. — Determination  of  the  degree  of 
gastric  evacuation.  At  this  stage  the  small  intestine  is  well  seen.  In  some 
cases  the  caecum  may  be  seen  commencing  to  fill. 

{d)  11  A.M.  Two  hours  after  the  meal. — The  normal  stomach  is  usually 
completely  empty,  the  csecum  well  filled. 

(e)  1  P.M.  Four  hours  after  the  meal. — Small  intestine  empty  ;  ascending 
colon  visible. 

(/)  7  P.M.  Ten  hours  after  the  meal. — The  large  intestine  is  visible  as  far 
as  the  left  flexure. 

{g)  Twenty  four  hours  after  the  m£al. — The  large  intestine  is  filled  as  far 
as  the  rectum. 

These  are  roughly  the  times  for  a  barium  meal ;  when  a  bismuth  salt  is 
used  the  time  given  must  be  proportionately  lengthened. 


VARIATIONS  IN  THE  TECHNIQUE 


217 


There  are  several  variations  from  the  routine  which  may  be  employed 
to  suit  individual  cases,  e.g.  the  screening  may  be  greatly  prolonged  when 
it  is  desirable  to  make  observations  on  the  motility  of  the  stomach,  or  in 
cases  of  irritable  stomach  with  or  without  duodenal  ulcer.  In  pyloric  ulcer 
or  cancer  of  the  pylorus  valuable  observations  may  be  made  by  the  screen 
method. 

Dr.  Jefferson,  working  in  the  X-ray  department  at  the  Cancer  Hospital, 
London,  has  obtained  a  number  of  most  interesting  plates  of  these  conditions. 
Conditions  of  the  alimentary  tract  commonly  met  with  vaW  best  be  shown 


Fig.  166. — Diagrams  to  illustrate  the  stages  of  a  bismuth  meal. 

•  a,  b,  and  c  show  the  stomach  in  process  of  filling  with  the  bismuth  food. 

d  shows  the  fully  distended  stomach  immediately  after  completion  of  the  meal. 

e,  Several  hours  after :  Food  passing  from  the  stomach  through  pylorus  into  duodenum  ;  food 
in  small  intestine. 

/,  Stomach  nearly  empty  ;  food  in  small  intestine  (ileum),  and  commencing  to  fill  up  the 
cfecum. 


by  taking  a  number  of  plates  dealing  first  with  the  normal  and  later  with 
the  departures  from  the  normal. 

The  radiographic  method  is  of  the  greatest  value  when  a  succession  of 
plates  can  be  obtained,  as  the  stomach  may  be  observed  during  the  process 
of  filling.  Small  quantities  may  be  watched  passing  into  the  organ  and 
taking  a  definite  course  along  the  lesser  curvature. 


218  KADIOGEAPHY 

Modifications  of  the  Opaque  Meal  for  Special  Investig-ations.— 

The  bismuth  or  barium  sulphate  may  be  made  very  thin  and  a  small  quantity 
given  when  we  wish  to  test  the  motility  of  the  stomach  carefully.  Having 
observed  the  movements,  the  next  step  is  to  fill  the  stomach  completely 
and  determine  its  position  and  size,  plates  or  drawings  being  taken  as  need 
arises. 

There  are  other  modifications  of  the  bismuth  meal  which  are  useful. 
Haenisch  recommends  the  following  method  for  the  investigation  of  the 
large  intestine  : 

Thoroughly  mix  500  grammes  of  warm  water  with  300  grammes  of 
kaolin  and  150  grammes  of  barium  sulphate  ;  then  add  500  grammes  more 
of  warm  water,  and  finally  150  grammes  of  barium.  To  inject,  introduce  a 
soft  rectal  rubber  tube  a  few  inches  into  the  rectum.  To  the  outside  end  of 
this  attach  a  few  inches  of  glass  tubing  (thus  enabling  the  injection  to  be 
seen),  from  which  india-rubber  tubing  is  led  to  a  douche  can.  Place  the 
barium  solution  in  the  can,  and  raise  it  to  allow  the  injection  to  flow.  The 
patient  is  lying  on  a  couch  with  the  X-ray  tube  below,  and  the  injection  is 
watched  upon  the  fluorescent  screen  ;  then  by  lowering  the  can  the  injection 
will  flow  from  the  bowel,  and  thus  any  abnormal  condition  can  be  studied 
with  the  solution  flowing  in  either  direction. 

Haudek's  Double-meal  Method. — A  bismuth  meal  is  given  at  7  o'clock, 
and  the  stomach  is  examined  at  1  o'clock  for  residue  or  otherwise,  and 
the  bowel  for  the  position  of  the  meal.  A  watery  infusion  of  bismuth 
is  then  given,  to  determine  the  size,  shape,  and  motility  of  the  stomach 
itself.  This  method  allows  of  the  whole  examination  being  made  at  one 
sitting,  and  certainly  shortens  the  time  during  which  the  patient  is  under 
observation.  On  the  other  hand,  it  is  not  reliable,  and  in  some  cases  many 
observations  require  to  be  made.  This  method  is  capable  of  further  modi- 
flcation.  Instead  of  the  watery  infusion  a  complete  barium  meal  may  be 
given.    The  whole  of  the  intestinal  tract  may  then  be  shown  at  different  times. 

Precautions  to  be  observed  in  the  Conduct  of  the  Examination. — 
With  the  screening-stands  and  tables  now  in  use,  the  distance  is  sufficiently 
great  to  prevent  any  serious  damage  to  the  patient  with  prolonged  screening ; 
but  where,  as  often  happens,  the  operator  is  not  fully  equipped  for  this  class 
of  work,  and  where  his  apparatus  is  not  sufficiently  powerful  to  ensure 
satisfactory  results,  he  is  tempted  to  approximate  the  tube  and  patient  as 
closely  as  possible,  and,  if  great  care  is  not  exercised,  the  skin  in  sensitive 
patients  may  be  severely  damaged.  Under  such  conditions  prolonged  screen- 
ing should  be  avoided.  When  it  is  necessary  to  screen  thoroughly  the  patient 
should  be  at  least  two  feet  from  the  anti-cathode  of  the  tube,  and  even 
then  the  interposition  of  a  thin  aluminium  filter  will  be  a  safeguard.  In 
cases  of  doubt  it  is  better  to  test  by  placing  a  Sabouraud  pastille  or  Kienbock 
paper  in  the  position  occupied  by  the  patient,  and  the  tube  allowed  to  run  for 
the  length  of  time  which  would  correspond  to  the  full  examination  con- 
templated. A  comparison  of  the  pastille  or  paper  with  the  usual  standards 
will  show  approximately  the  dose  which  would  be  administered  to  the  skin 


PLATE  XLIII. — Stomach  and  Colon  showing  Yiscekoptosis. 

a,  Abdomen  before  the  meal ;  this  shows  the  shadows  caused  by  gas  in  the  stomach  and  large 
intestine. 

•  b,  Stomach  well  filled,  situated  low  down  in  the  pelvis,  elongated, 
c,  Stomach  emptying  slowly. 


KADIOGRAPHIC  APPEARANCES  OF  THE  STOMACH        219 

surface  during  the  examination.     In  this  way  it  is  possible  to  save  damage 
to  the  patient  and  anxiety  to  the  operator. 

Radiographic  Appearances. — Holzknecht,  in  an  exhaustive  paper  on 
the  bismuth  examination  of  the  stomach,  groups  radiographical  and  clinical 
signs  under  one  "  symptom  complex,"  so  as  to  show  their  true  diagnostic 
value. 

This  is  a  most  important  step  in  technique.  Clinical  signs  and  symptoms 
should  always  be  considered  together  with  the  radiographical  findings,  if 
we  wish  to  get  the  best  value  from  the  examination.  A  consideration  of 
the  clinical  signs  will  often  determine  the  exact  method  of  investigation  we 
should  employ,  and  will  save  time. 

He  describes  a  number  of  groups  ;  two  examples  \n^1  illustrate  the 
method  : 

Symptom  Complex  A.— (1)  Bismuth  residue  six  hours  after  meal ;  (2) 
Normal  shadow  of  stomach  seen  on  the  screen  ;   (3)  Achylia. 

Diagnosis  :   a  small  carcinoma  of  the  pylorus. 

Symptom  Complex  B. — (1)  Small  bismuth  residue  after  six  hours  ;  (2) 
Sensitive  pressure  point  and  resistance  in  the  pars  media  ;  (3)  transverse 
contraction  of  the  pars  media ;  (4)  diverticulum,  without  an  air  bubble  in 
the  small  curvature  ;   immovable. 

Diagnosis  :   a  callous  ulcer  of  the  small  curvature  of  the  pars  media. 

He  lays  great  stress  upon  the  importance  of  hyperacidity  or  otherwise, 
and  many  of  the  X-ray  diagnoses  are  based  upon  the  X-ray  findings,  plus  or 
minus  the  acidity.  Thus  in  Symptom  Complex  A  the  diagnosis  is  made 
on  the  following  points  :  (1)  As  long  as  the  pylorus  is  free,  achylia  is 
always  associated  with  hypermotility  in  an  empty  stomach  in  from  two 
to  three  hours  ;  (2)  A  residue  after  six  hours  must  mean  organic  obstruc- 
tion ;  (3)  Spasm  of  the  pylorus  is  never  associated  with  achylia  but  with 
hyperacidity. 

The  X-ray  findings  may  be  diagnostic  of  simple  ulcer  or  malignant 
disease.  In  the  former  the  ulcer  is  rarely  seen,  but  if  the  case  is  observed  on 
the  screen  the  presence  of  the  ulcer  may  be  suspected  from  the  absence  of 
shadows  indicating  the  passage  of  food  through  the  pylorus.  In  malignant 
disease  involving  the  lesser  curvature  and  spreading  round  the  pylorus, 
the  latter  point  is  more  or  less  fixed,  and  held  higher  up  than  usual ; 
food  may  be  seen  passing  through  the  stricture  ;  a  sharp  and  persistent 
angle  or  irregularity  in  the  pyloric  region  is  generally  indicative  of  maUgnant 
stricture ;  finally,  a  shadow  of  the  growth  may  at  times  be  seen  on  the 
radiographs. 

Rieder  and  Rosenthal  have  demonstrated  the  normal  and  abnormal 
contractions  of  the  stomach  wall  by  a  method  of  cinematography.  They 
take  8  or  9  pictures  in  rapid  succession.  An  outline  sketch  is  taken  of  each 
on  transparent  paper,  the  whole  are  superimposed,  and  a  picture  obtained  of  a 
peristaltic  wave  passing  along  the  whole  organ.  Definite  departures  from  the 
normal  are  indicated  by  an  arrest  of  the  contraction  wave  at  one  particular 
spot,  showing  the  presence  of  an  ulcer,  which  may  be  simple  or  malignant. 


220  KADIOGEAPHY 

The  value  of  an  X-ray  examination  of  the  stomach  is  great,  but  reliance 
should  not  be  placed  on  it  alone.  Repeated  examination  should  be  made 
and  chemical  examinations  carried  out  simultaneously,  and,  lastly,  full 
consideration  should  be  given  to  the  history  of  the  case  and  the  palpation 
of  the  stomach  at  the  time  of  the  examination. 

Variations  in  the  Position  and  Size  of  the  Stomach.— The  normal 
stomach  is  variable  in  form  and  position.  There  are  certain  types  which 
must  be  considered  normal  since  each  is  capable  of  performing  its  normal 
function.  Later  anatomical  studies  undoubtedly  prove  that  the  living 
stomach  is  correctly  shown  by  the  Rontgen  picture.  Variations  in  the  shape 
and  size  of  the  normal  stomach  have  been  described  ;  but  radiographic 
interpretation  would  be  facilitated  if  the  division  into  groups  according  to 
muscular  tone  were  adhered  to  in  the  future,  these  groups  being  of  the 
hypertonic,  orthotonic,  hypotonic,  and  atonic  forms.  These  are  illustrated 
diagrammatically  below. 

Hypertonic.  Orthotonic.  Hypotonic.  Atonic. 

Fig.  167. — Types  of  stomach. 

The  emptying  time,  or  normal  period  taken  to  empty  these  different 
types  of  stomach  of  the  opaque  meal,  is  an  additional  aid  in  differentiating 
each  type.  The  hypertonic  requires  from  two  to  three  hours  to  empty 
itself,  the  orthotonic  three  to  five  hours,  the  hypotonic  four  to  six  hours, 
and  the  atonic  six  to  eight  hours. 

The  form  of  the  normal  stomach  and  its  position  depend  largely  upon 
the  shape  of  the  upper  abdomen  and  the  general  anatomical  characteristics 
of  the  individual.  When  the  intercostal  angle  is  wide  and  the  upper  abdomen 
is  broad,  the  stomach  assumes  an  oblique  position.  With  a  narrow  upper 
abdomen  and  a  more  acute  intercostal  angle,  the  stomach  is  perpendicular. 
Thus,  in  some  individuals  an  atonic  type  of  stomach  is  normal,  i.e.  if  its 
function  is  not  delayed,  while  the  same  type  in  an  individual  of  a  different 
build,  but  incapable  of  emptying  itself,  is  the  result  of  a  ptosis.  Again  a 
hypertonic  form  of  stomach  may  be  found  where  the  abdomen  is  broad 
and  the  intercostal  angle  wide,  and  yet  it  will  be  found  to  be  orthotonic  or 
even  hypotonic. 

Functional  Disturbances  of  the  StomSLGh.— Tonicity  of  the  Stomach. 
— The  phenomena  observed  while  the  opaque  meal  is  passing  into  the 
stomach.     The  manner  in  which  the  opaque  meal  enters  the  stomach  is 


PLATE  XLIV. — Stomach  and  Colon  showing  Visceroptosis. 

«,  Six  hours  after  ingestion  of  food,  stomach  still  containing  considerable  quantitj'  of  food. 

h,  Two  hours  later,  eight  hours  after  ingestion,  stomach  contracting  vigorously  on  the  bismuth  residue. 

c.  Twenty-four  hours  after  meal  :  food  in  colon. 


FUNCTIONAL  DISTURBANCES  OF  THE  STOMACH         221 

an  indication  of  its  muscular  tone.  The  empty  normal  stomach  hes  in 
the  form  of  a  collapsed  tube,  with  its  walls  in  contact,  except  in  the  fundus, 
which  contains  the  so-called  magenblase.  {See  Fig.  164.)  A  portion  of 
the  opaque  meal  is  first  seen  in  the  upper  part  as  a  funnel-shaped  shadow, 
which  is  quickly  forced  downwards,  separating  the  walls,  and  finally  reach- 
ing the  sinus,  and  filling  the  pyloric  canal.  The  length  of  the  stomach 
remains  fixed,  while  the  corpus,  sinus,  and  pyloric  canal  increase  in  girth,  and 
accommodate  themselves  to  the  amount  of  the  meal  ingested.  This  type  of 
filling  phenomena  is  characteristic  of  the  orthotonic  stomach.  In  contrast 
to  this,  the  opaque  meal  in  entering  an  atonic  stomach  seems  to  fall  through 
the  corpus  directly  into  the  sinus.  The  direction  of  the  passage  of  the  meal 
is  outwards  and  downwards  to  the  left. 

In  a  markedly  atonic  stomach  the  distension  commences  in  the  sinus, 
the  opaque  meal  collecting  there  in  a  half-moon  form,  while  the  walls  of  the 
body  remain  in  contact,  and  the  fornix  filled  with  gas  preserves  a  more  or 
less  oval  form.  Gross  changes  in  the  contour  of  the  stomach  can  be  observed 
during  the  ingestion  of  the  opaque  meal.  The  benign  and  the  malignant 
hour-glass  stomach  differ  entirely  in  filling  phenomena  from  the  normal 
stomach. 

The  Motility  of  the  Stomach. — Definite  conclusion  as  to  the  motility  of 
the  stomach  can  be  arrived  at  from  the  study  of  the  swaying  intensity  and 
form  of  the  peristaltic  waves,  and  the  time  required  for  the  opaque  meal  to 
pass,  when  combined  with  the  information  given  by  the  shape,  position,  and 
form  of  the  residue  remaining  in  the  stomach.  These  peristaltic  waves  can 
be  shown  on  the  fluorescent  screen.  Rieder  and  Rosenthal  have  shown  the 
complete  wave  by  means  of  a  number  of  radiographs  taken  in  rapid  succes- 
sion. The  late  Dr.  Leonard  showed  that  there  is  a  constant  change  in  the 
length  and  breadth  of  the  stomach  during  every  cycle  of  respiration.  It  has 
been  noted  by  surgeons  during  operations  under  anaesthetics,  that  while 
peristalsis  is  absent  and  the  sphincters  are  relaxed,  the  contents  of  the 
stomach  are  ejected  into  the  duodenum  in  jets  synchronous  with  the  re- 
spiratory movements. 

The  form  and  depth  of  the  peristaltic  wave  differ  in  the  varying  types 
of  stomach,  and  in  the  same  stomach  with  the  patient  in  different  positions. 
It  also  varies  with  the  character  of  the  ingesta. 

The  Time  taken  by  the  Stomach  to  Empty. — The  relation  of  the  empty- 
ing time  of  a  stomach  to  that  of  the  normal  type  is  the  most  accurate  way 
of  determining  its  motor  efficiency.  Thus,  as  already  stated,  it  has  been 
determined  that  the  emptying  time  of  the  four  types  of  stomach  is  as 
follows  : 

A  standard  Rieder  meal  of  350  grammes  of  food  and  50  grammes  of 
bismuth  should  pass  through  the  hypertonic  stomach  in  two  to  three  hours, 
the  orthotonic  in  three  to  five,  the  hypotonic  in  four  to  six,  and  the  atonic  in 
six  to  eight  hours  ;  the  presence  of  a  residue  of  bismuth  in  a  stomach  of  any 
one  of  these  types,  after  the  normal  time  for  that  type,  shows  that  there  is 
deficient  motility.     Differences  will  be  found  to  occur  according  to   (a) 


222       ^  RADIOGRAPHY 

modifications  of  the  quantity  of  food  and  bismutli,  (b)  the  substance  used 
to  render  the  meal  opaque,  and  (c)  the  placing  of  the  patient  in  different 
positions.  As  far  as  possible  the  examinations  should  be  made  in  the  up- 
right position,  the  recumbent  position  being  used  in  most  cases  as  a  check 
observation.  No  other  food  should  be  taken  by  the  patient  until  the 
stomach  has  emptied  itself,  or  until  the  observer  has  determined  that  no 
further  observation  on  the  emptying  time  of  the  stomach  is  necessary. 

Pathological  Conditions  of  the  Stomach.— The  excellent  summary 
of  these  conditions  by  the  late  Dr.  Lester  Leonard,  in  his  report  to  the 
Radiology  Section  of  the  International  Congress,  held  in  London  in  August 
1913,  is  so  complete  that  this  part  of  the  work  will  be  largely  modelled  on 
his  lines. 

Disturbances  of  Secretion. — The  Schwartz  capsule  may  be  employed  to 
estimate  the  amount  of  free  hydrochloric  acid  in  the  stomach.  This  capsule 
is  made  of  gold-beaters'  skin  of  known  thickness,  containing  4  grammes  of 
chemically  pure  bismuth  and  25  grammes  of  pure  neutral  pepsin  ;  the  latter 
is  added  to  hasten  the  digestion  of  the  capsule,  so  that  it  will  occur  within 
five  hours,  and  to  make  the  time  of  digestion  entirely  dependent  upon  the 
amount  of  hydrochloric  acid  by  providing  an  excess  of  pepsin.  By  experi- 
ments in  vitro  the  time  has  been  determined  which  is  required  to  digest  the 
capsule  with  fixed  amounts  of  free  hydrochloric  acid.  These  results  were 
found  to  conform  to  the  time  taken  to  digest  these  capsules  in  a  large  series 
of  cases.  The  patient  is  given  in  the  morning,  while  fasting,  a  test  meal 
consisting  of  200  grammes  and  a  measured  quantity  of  bread.  The  capsule 
is  taken  and  observations  made  at  regular  intervals  by  means  of  the  fiuor- 
escent  screen,  in  order  to  see  when  the  capsule  is  digested  as  indicated  by 
dissipation  of  the  bismuth. 

Pathological  Changes  in  the  Form  and  Position  of  the  Stomach. — While 
studying  the  changes  in  position  and  shape  of  the  stomach  itself,  one  must 
bear  in  mind  those  changes  due  to  pressure  from  without.  Among  these 
may  be  mentioned  pregnancy ;  tumours  of  the  viscera,  such  as  fibromata, 
cystic  conditions,  or  tumours  involving  the  abdominal  walls.  The  presence 
of  peritoneal  bands  or  adhesions  must  also  be  considered.  These  may  be 
suspected  when  during  an  examination  any  particular  part  of  the  organ 
appears  to  be  unduly  fixed,  or  when  the  whole  organ  is  relatively  higher  than 
normal.  These  adhesions  are  a  frequent  accompaniment  of  healed  gastric 
ulcer,  inflammatory  conditions  of  the  gall-bladder,  etc. 

Ptosis.— The  most  obvious  and  frequent  change  noted  in  the  stomach 
is  that  of  ptosis.  In  true  gastroptosis  the  bismuth  meal  is  seen  to  fall 
through  the  stomach  quickly,  the  lack  of  muscular  tone  allowing  the  food 
to  pass  rapidly  through  and  collect  in  the  sinus.  The  pylorus  and  oesophagus 
with  the  fornix  are  firmly  fixed  by  their  ligaments,  and  the  ptosed  stomach 
therefore  increases  in  vertical  length,  the  bismuth  meal  distending  the  lower 
portion  of  the  stomach,  while  in  the  median  part  of  the  body  the  walls  are 
approximated,  the  fornix  being  generally  distended  with  gas.  The  peri- 
staltic waves  are  almost  entirely  absent  in  the  erect  position,  and  show  then 


PLATE  XLV. ^OPAQUE  Meal  in  Stomach  and  Colon. 

a,  Opaque  meal  in  stomach  twenty-four  hours  after  ingestion  ;  pyloric  obstruction  confirmed  at  operation. 
h,  Delay  in  stomach  due  to  adhesions  at  pylorus,  which  was  attached  to  anterior  abdominal  wall, 
c,  Colon  from  the  same  patient,  showing  a  sharp  bend  in  transverse  colon,  which  was  adherent  to 
anterior  abdominal  wall,  confirmed  by  oijeration. 


ULCER  OF  THE  STOMACH 


223 


only  in  the  pyloric  canal.  They  are  more  frequent  and  deeper  when  the 
patient  lies  down.  In  most  of  these  cases  a  condition  of  atony  of  the  stomach 
wall  supervenes.  Then  great  dilation  may  follow,  though  the  atony  may 
be  compensated  for  by  muscular  hypertrophy.  In  ptosis  with  atony  the 
stomach  is  incapable  of  emptying  itself 
for  six  to  eight  hours,  or  even  longer, 
after  ingestion  of  the  meal. 


Fig.  168.— To  show  position  of  stomach  p^^     169.— Diagrammatic    representation    of 

in  ptosis.     Pylorus  is  also  dropped.  pyloroptosis,    with     some     atony     of     the 

Dotted    line   represents    the   normal  stomach, 
position. 

Pyloroptosis. — This  is  a  pronounced  form  of  ptosis,  involving  the 
pylorus,  which  is  often  as  low  as  the  fifth  lumbar  vertebra. 

Ulcer  of  the  Stomach.— Hhe  diagnosis  of  gastric  ulcer  by  the  Eontgen 
method  is  one  of  its  greatest  advances.  The  extent  to  which  the  stomach 
wall  has  been  involved  in  the  pathological  process  influences  the  accuracy 
of  the  diagnosis,  simple  ulcer  involving  only  the  gastric  mucosa  being  the 
most  difficult  to  distinguish.  Perforating  ulcers  that  involve  the  muscular 
wall  can  be  recognised  in  a  much  larger  percentage  of  cases,  while  perforating 
ulcer  of  the  callous  type  can  be  detected  in  the  majority  of  cases.  Chronic 
ulcers  with  or  without  perforation  that  have  produced  contractions,  present 
a  picture  of  hour-glass  contraction,  and  are  easily  recognised. 

Care  should  be  taken  to  watch  the  meal  entering  the  stomach.  Hour- 
glass contraction  can  readily  be  recognised,  and  the  presence  of  a  narrow 
canal  between  the  two  segments  is  diagnostic.  A  large  shadow  in  the  upper 
segment  is  often  clearly  seen,  soon  a  fine  pencil  of  bismuth  may  be  detected 
passing  through  the  stricture,  and  later  the  whole  of  the  meal  may  be  located 
in  the  lower  segment.  This  class  of  case  must  be  differentiated  from  the 
malignant  hour-glass  contraction  and  the  intermittent  and  pseudo  hour- 
glass contraction.  Perforating  hour-glass  contraction,  which  has  not 
changed  the  form  of  the  stomach  through  the  contraction  of  scar  tissue,  is 
the  most  readily  diagnosed  ulcerative  condition,  except  hour-glass  contrac- 
tion. Haudek  first  established  their  radiographic  diagnosis,  and  has  formu- 
lated their  Eontgenologic  symptom  complex  and  signs  as  follows  : 


224  RADIOGRAPHY 

(1)  A  diverticular  projection  from  the  stomach  shadow,  mostly  on  the 
lesser  curvature. 

(2)  Movability  of  the  bismuth  mass  by  palpation. 

(3)  The  persistence  of  a  bismuth  shadow  at  a  particular  point. 

(4)  A  hemispherical  collection  of  gas  above  the  bismuth  shadow. 

(5)  The  constant  and  marked  contraction  of  the  greater  curvature  of 
the  stomach  at  a  point  opposite  to  the  shadow,  approximating  in  form  to  an 
hour-glass  contraction. 

(6)  A  displacement  to  the  left  of  the  pyloric  portion  of  the  stomach, 
especially  noticeable  in  males,  with  a  perpendicular  outline  on  the  right 
border  of  the  greater  curvature. 

(7)  A  retardation  of  motility,  so  that  six  hours  after  the  ingestion  of  the 
bismuth  meal  a  large  portion  remains  in  the  stomach.  This  residue  is  placed 
to  the  left  of  the  median  line  when  the  ulcer  lies  high. 

(8)  Antiperistalsis. 

(9)  The  presence  of  an  acutely  tender  spot,  with  a  sense  of  resistance  on 
pressure,  in  the  epigastrium,  in  the  region  of  the  left  rectus  muscle.  This  is 
frequently  seen  in  ulcer  of  the  body  of  the  stomach. 

It  is  of  practical  importance  to  remember  that  these  ulcers,  while 
occurring  most  frequently  on  the  lesser  curvature  of  the  stomach,  may  be 
found  on  the  anterior  and  posterior  walls.  During  the  examination,  there- 
fore, the  patient  must  be  rotated,  or  the  tube  displaced  from  side  to  side,  in 
order  to  bring  ulcers  in  these  positions  to  the  profile  of  the  stomach  shadow. 
Unless  this  is  done  they  will  be  entirely  hidden  by  the  mass  of  bismuth  in 
the  stomach,  and  escape  detection. 

The  neighbouring  organs  most  frequently  involved  in  perforating 
ulcers  are  the  liver  and  spleen.  When  the  liver  is  involved  the  shadow  rises 
and  falls  with  respiratory  movements. 

Callous  Ulcers. — The  most  common  seat  of  callous  ulcers  is  upon  the 
lesser  curvature  of  the  stomach,  the  contraction  due  to  cicatricial  changes 
after  healing  giving  rise  to  a  shortening  of  the  lesser  curvature.  Haudek 
has  pointed  out  that  this  leads  to  a  dragging  of  the  pylorus  to  the  left,  and 
has  shown  that  a  difEerence  can  be  noted  in  the  shape  and  position  of  the 
residue  in  the  sinus  and  its  relation  to  the  bulbus  duodeni.  In  perforating 
callous  ulcers,  and  in  florid  ulcers  with  or  without  penetration,  the  residue  in 
the  sinus  has  a  sharp,  straight,  almost  perpendicular  outline  on  the  right 
side,  with  the  shadow  of  the  bulbus  duodeni  to  the  left  of  the  umbilicus,  and 
nearly  above  the  sinus.  In  carcinoma  of  the  pylorus  the  residue  has  a  poorly 
defined  jagged  right  border,  while  the  bulbus  duodeni  is  well  to  the  right  of  the 
umbilicus.  In  uncompensated  stenosis  of  the  pylorus  the  residue  is  broader, 
is  drawn  out  in  the  form  of  a  crescent,  and  extends  to  the  right  and  left  of 
the  middle  line,  while  the  shadow  of  the  bulbus  duodeni  is  far  to  the  right. 

Plate  XLII.  illustrates  phases  in  the  passage  of  the  food  from  the 
stomach  in  pyloric  stenosis. 

Plate  XL  v..  Fig.  a  illustrates  the  appearance  shown  by  the  bismuth  food 
in  a  large  atonic  stomach,  with  pyloric  stenosis,  due  to  the  healing  contraction 


PENETRATING  ULCER  OF  THE  STOMACH 


225 


occurring  in  pyloric  ulcer.      Note  the  level  upper  surface  of  the  bismuth 
shadow. 

Penetrating  Ulcer. — Penetrating  ulcer  of  the  stomach  differs  markedly 
from  perforating  ulcer,  in  that  instead  of  the  rounded  diverticulum  filled 
with  bismuth  and  gas,  there  is  only  a  slight  bud  or  spur-like  projection  from 
the  profile  of  the  stomach  shadow.  The  right  lateral  portion  is  of  value  in 
these  cases.  A  variation  in  the 
technique  is  described  by  Schwartz, 
in  which  he  employs  a  watery  solu- 
tion of  bismuth  in  small  quantity. 
It  is  used  with  the  patient  on  the 
back.  The  patient  is  then  turned 
gently  first  on  one  side  and  then 
on  the  other,  and  finally  on  the 
abdomen.  This  is  to  coat  the 
mucosa,  so  that  shallow  ulcers  will 
retain  a  small  amomit  of  bismuth, 
when  the  patient  stands  erect.  He 
has  succeeded  in  this  manner  in 
locating  small  ulcers  on  the  posterior 
wall  of  the  stomach.  The  simple 
idcer  is  the  most  difl&cult  to  demon- 
strate, and  is  frequently  missed 
altogether.  The  florid  or  indurated 
ulcer,  either  with  or  without  erosion, 
is  also  very  difficult  to  recognise, 
as  are  also  ulcers  situated  in  the  ^pyloric  canal  or  in  the  neighbourhood. 
Except  in  rare  cases  of  perforating  ulcer,  the  X-ray  picture  is  not  definite. 
The  diagnosis  must  be  based  on  the  obstructive  signs  : 

(1)  The  spasm  of  the  pylorus  is  more  marked ;  (2)  there  is  a  decrease 
of  the  motility,  and  a  large  residue  of  the  bismuth  meal  is  left  in  the  stomach 
after  six  hours.  This  is  the  result  of  the  intermittent  opening  of  the  pylorus 
in  the  presence  of  spasm. 

If  care  is  taken  to  examine  the  patient  frequently  at  the  time  when 
the  food  is  engaging  in  the  pylorus,  a  small  streak  of  the  bismuth  is  occasion- 
ally, seen  entering  and  passing  through  the  narrow  canal.  It  may  remain 
for  an  appreciable  time  in  the  stricture. 

Pseudo  Contractions  of  the  Stomach.— Hhese  are  the  result  apparently  of 
various  neuroses  that  produce  a  contraction  of  the  greater  curvature.  A 
deep  infolding  of  the  greater  curvature  of  the  stomach  is  the  result  of  these 
contractions.  Atropine  given  hyperdermically  frequently  aids  in  clearing 
up  the  diagnosis.  This  type  must  be  differentiated  from  the  intermittent 
hour-glass  contraction  of  the  stomach  as  well  as  from  the  benign  and  malig- 
nant hour-glass  contraction. 

Intermittent  Hour-glass  Contraction. — This  may  simulate  in  every  detail 
the  true  hour-glass  contraction.     It  may  take  the  form  of  a  contraction  in 

15 


Fig.  170. — Diagram  to  represent  a  condition  met 
with  iu  examination  of  the  stomach.  This  is 
typical  of  atony  of  the  stomach  walls  secondary 
to  pyloric  obstruction. 


226 


RADIOGKAPHY 


the  middle  of  the  stomach,  with  apparently  two  equal  portions  ;  or  the  upper 
segment  may  contain  all  the  meal  with  the  magenblase  well  marked  above. 
The  greater  curvature  shows  a  marked  depression  in  other  cases.     There 

is  no  retardation  of 
motility,  and  there  may 
be  even  an  increased 
rapidity  of  emptying,  the 
administration  of  atro- 
pine leading  to  no  change 
in  the  condition.  Such 
cases  require  to  be  ex- 
amined on  more  than  one 
occasion  before  an  accu- 
rate diagnosis  can  be 
made.  There  is  never 
any  residue  after  six 
hours.  The  normal 
stomach  picture  will  be 
obtained  on  one  examination,  and  the  hour-glass  contraction  at  another 
time.  The  appearance  of  hour-glass  contraction  may  be  reproduced  in  the 
same  patient  on  more  than  one  occasion.  It  is  possible  that  the  condition 
of  the  colon,  bound  by  adhesions,  may  be  an  explanation  of  the  contraction. 
True  Hour-glass  Contraction. — There  are  three  varieties  met  with  : 
(1)  Congenital ;    (2)  Non-malignant ;    (3)  Malignant. 

(1)  The  existence  of  true  congenital  hour-glass  contraction  is  doubted 
by  many  authorities,  and  when  it  does  occur  it  may  be  regarded  as  an 
anatomical  curiosity. 

(2)  The  non-malignant  form  is  generally  due  to  the  existence  of  ulcera- 
tion of  the  stomach  wall,  with  resulting  cicatricial  changes,  leading  to  con- 


FlG.  171. — Hour-glass  stomach.  Photograph  from  a  post- 
mortem specimen.  Shows  a  well-marked  constriction,  result- 
ing from  a  healed  ulcer.  There  were  a  number  of  small  active 
ulcers  in  both  segments  of  the  stomach. 


Upper 


Communicating 


Lower  sac  com- 
mencing to  fill 


Upper  sac 


Channel 


Pylorus 

Fig.  172. — Hour-glass  contraction  of  the  stomach. 
(1)  Soon  after  ingestion  of  food.        (2)  Several  hours  after  ingestion. 

traction  in  particular  parts  of  the  walls,  ulceration  generally  beginning  on 
the  lesser  curvature  of  the  stomach.  The  frequency  of  hour-glass  contraction 
is  probably  greater  than  was  at  one  time  supposed.     No  doubt  many  more 


PLATE  XLVI. — Hour-glass  Contraction  of  the  Stomach. 


«,  Shortly  after  ingestion  of  barium  meal.  Note  shape  of  stomach  and  small  portion  of  the 
meal  engaging  in  a  narrow  channel  of  communication. 

h,  Same  stomach  several  hours  later  ;  the  greater  portion  of  the  meal  is  now  in  the  lower  sac. 
Upper  sac  is  empty,  nearly  all  of  the  meal  is  now  in  the  lower  sac.  Eight  hours  after  ingestion 
very  little  of  the  food  has  passed  through  the  pylorus. 

c,  Radiograph  taken  at  ten  hours,  and  later  showed  marked  delay  in  emptying  time  of  stomach. 

Diagnosis,  hour-glass  contraction  of  stomach,  also  pyloric  stenosis  secondary  to  another  iilcer, 
confirmed  by  operation. 


MALIGNANT  HOUR-GLA88  CONTRACTION  227 

cases  are  now  recognised,  as  "a  result  of  improvements  in  the  technique  of 
examination.  The  entrance  of  food  into  the  stomach  is  an  important 
feature  in  diagnosis  ;  the  opaque  meal  collects  in  the  upper  zone  of  the  organ, 
and  only  gradually  passes  through  the  tortuous  canal  into  the  pyloric  portion. 
The  appearance  of  an  hour-glass  stomach  is  quite  typical,  and  not  likely  to 
be  overlooked  when  once  it  has  been  seen.  The  emptying  time  is  necessarily 
increased  by  the  delay  in  passing  from  one  portion  of  the  stomach  to  the 
other,  spasmodic  contractions  also  in  part  adding  to  the  already  lengthened 
emptying  period.  Benign  hour-glass  contraction  may  also  be  combined  with 
ulcerative  pyloric  stenosis  ;  or  several  acute  ulcers  may  be  present  in  a 
stomach  which  has  at  an  earlier  date  had  an  ulceration  at  the  lesser 
curvature,  with  the  subsequent  formation  of  an  hour-glass  contraction. 
Fig.  171  shows  a  post-mortem  stomach,  which  is  markedly  hour-glass  ;  it 
had  several  small  ulcers  in  both  segments. 

Malignant  Hour-Glass  Contraction. — The  invasion  and  concentric 
spread  of  a  growth  in  the  circumference  of  the  body  of  the  stomach  results 
in  an  hour-glass  form  of  stomach,  the  growth  spreading  in  all  directions, 
upwards,  downwards,  and  concentrically,  though  the  growth  may  not  be 
equal  in  all  directions.  The  resulting  Rontgen  picture  is,  therefore,  not  only 
one  of  lacunar  biloculation,  but  also  of  a  ragged  irregularity  and  deficiency 
in  the  stomach  shadow,  which  may  have  a  funnel-shaped  entrance  and  exit. 
The  food  on  entering  the  stomach  passes  directly  through  the  canal,  if  it  has 
any  degree  of  lumen,  into  the  lower  pole  of  the  stomach.  The  emptying 
may  not  be  delayed,  unless  the  pylorus  is  also  involved.  In  malignant 
disease  the  normal  relations  are  more  nearly  maintained,  as  there  is  not  so 
much  displacement  due  to  cicatricial  contractions.  The  question  of  a  callous 
ulcer  taking  on  the  malignant  characteristics  must  be  referred  to.  In  all 
probability  the  great  majority  of  simple  ulcers  remain  so  to  the  end,  evidence 
being  rarely  produced  to  show  that  the  malignancy  has  been  implanted  on 
a  chronic  simple  ulceration.  The  possibility  of  such  an  occurrence  renders 
an  absolute  differential  diagnosis  impossible  in  all  cases. 

Cancer  of  the  Stomach. — This  is  one  of  the  most  important  diseases  for 
the  use  of  Rontgen  rays  in  diagnosis,  for  in  no  situation  is  the  early  diagnosis 
of  cancer  so  essential  as  when  it  locates  itself  in  the  stomach.  Taken  in 
conjunction  with  the  history  and  the  evidence  of  chemical  examinations 
by  means  of  the  test  meal,  the  Rontgen  method  completes  the  picture,  and 
enables  us  to  make  a  positive  diagnosis  not  only  of  the  presence  of  a  growth, 
but  also  of  its  position  and  size,  the  involvement  of  neighbouruig  organs, 
and  the  possibility  of  an  early  radical  operation.  This  point  has  been  well 
demonstrated  by  repeated  examinations  of  cases.  Several  illustrations  are 
given  to  show  the  value  of  a  thorough  bismuth  meal  examination. 

Carcinoma  may  be  found  in  any  portion  of  the  stomach,  the  most  com- 
mon situations  being  the  cardiac  orifice,  the  pylorus,  with  the  adjoining 
stomach  wall,  and  the  lesser  curvature  of  the  body  of  the  stomach.  The 
characteristic  appearance  is  that  of  a  stomach  shadow  more  or  less  ragged 
and  irregular  in  a  part  of  its  extent,  with  generally  a  delay  in  the  passage  of 


228  RADIOGRAPHY 

the  food  :  masses  of  the  growth  project  into  the  bismuth  food,  and  so  cause 


Fig.  173. — Three  examples  of  carcinoma  of  the  stomach.     (Haudek.) 

irregularities  of  the  shadow.     All  cases  examined  which  show  irregularity 
should  be  re-examined  in  order  to  confirm  the  diagnosis. 


Fig.  174. — Illustrating  the  appearances  seen 
in  carcinoma  at  pyloric  end  of  stomach. 
The  shaded  area  represents  the  tumour. 


1  2 

Fig.  175. — Situations  of  tumour  of  stomach. 

(1)  Tumour  situated  near  the  cardiac  end  of  the 
stomach.  The  stomach  in  this  case  contained  bismuth 
food  twenty-four  hours  after  ingestion.  There  was 
no  pyloric;  obstruction  found  at  the  operation. 

(2)  Large  carcinoma  involving  lesser  curvature. 
The  stomach  emptied  rapidly  in  this  case.  A  large 
tumour  was  found  converting  the  lumen  of  the 
stomach  into  a  funnel-shaped  channel.  ■ 


Malignant  disease  in  other 
organs  may  press  upon  the  stomach, 
and  so  give  an  erroneous  impres- 
sion that  this  organ  is  involved  ; 
in  a  particular  instance  the  stomach  at  operation  proved  quite  free 
from  growth.  Infiltrating  malignant  disease  results  in  a  thickening  and 
hardening  of  the  stomach  walls,  producing  a  form  of  stomach  like  the 
hypotonic.  Peristalsis  is  wanting,  sometimes  to  a  marked  degree,  in  the 
portion  of  stomach  wall  involved,  and  the  whole  stomach  may  be  converted 
into  a  rigid  canal  of  small  calibre,  through  which  the  bismuth  meal  flows 
quickly  into  the  duodenum.  In  carcinoma  of  the  pylorus  the  defects  in  the 
stomach  shadow  vary  in  form  with  the  extent  and  position  of  the  tumour. 


THE  SMALL  INTESTINE  229 

Examination  of  the  Small  Intestine 

Bismuth  food  passes  so  rapidly  through  the  small  intestine  that  the 
determination  of  a  peristaltic  wave  is  a  matter  of  great  difficulty.  With  the 
exception  of  a  small  mass  in  the  bulbus  duodeni,  and  the  collection  of  masses 
in  the  convoluted  portion  of  the  ileum,  little  is  seen  in  normal  cases,  but 
rapid  radiographs  show  small  flakes  scattered  throughout  the  duodenum, 
jejunum,  and  the  upper  portion  of  the  ileum.  It  is  very  important  to  be 
able  to  demonstrate  the  duodenum  in  the  normal  condition,  and  in  morbid 
conditions  due  to  various  causes. 

The  Duodenum. — The  duodenum  comprises  the  first  nine  or  ten  inches 
of  the  small  intestine.  It  passes  from  the  pyloric  end  of  the  stomach,  at 
first  backwards  and  then  downwards,  until  it  disappears  behind  the  transverse 
colon.  Passing  to  the  left  of  the  spine,  it  ascends  for  a  short  distance,  and  at 
the  level  of  the  second  or  third  lumbar  vertebra  passes  into  the  jejunum, 
forming  a  sharp  bend  forwards  and  downwards,  which  is  named  the 
duodeno-jejunal  flexure.  It  makes  a  curve  round  the  head  of  the  pancreas. 
The  first  portion  is  nearly  horizontal,  and  is  free  and  movable  like  the 
stomach.  The  second  or  middle  portion  descends,  and  is  about  3  inches 
in  length.  The  third,  or  inferior  portion,  is  the  longest  of  all.  After 
crossing  from  right  to  left  of  the  spine  it  ascends  to  end  in  the  jejunum, 
opposite  the  second  or  third  lumbar  vertebra. 

The  bismuth  meal  passes  rapidly  through  the  duodenum,  in  from  25 
to  60  seconds.  Special  technique  is  necessary  to  show  successfully  the 
duodenum  in  the  normal  subject,  departures  from  the  normal  being  more 
easily  shown.  Observations  on  the  duodenum  may  be  made  with  the 
patient  standing  up  or  lying  on  the  X-ray  couch.  It  is  better  to  examine  the 
patient  in  the  upright  position,  centering  the  tube  over  the  pyloric  end  of  the 
stomach.  A  sHght  degree  of  lateral  rotation  of  the  patient  throws  the 
duodenum  well  into  the  field  of  vision,  and  on  screening,  the  bismuth  is  seen 
throughout  its  whole  course  along  the  duodenum.  Jordan  describes  a 
method  by  which  he  claims  to  be  able  to  demonstrate  the  duodenum  in  nearly 
every  case.  He  uses  a  preparation  of  bismuth  carbonate  with  sugar  of  milk, 
and  examines  the  patient  in  the  right  lateral  position  upon  the  X-ray  table. 
His  special  technique  for  the  examination  of  the  duodenum  is  as  follows  : 

Method  of  Examination  for  Intestinal  Stasis 

The  patient  takes  his  usual  breakfast.  About  one  or  two  hours  later  he 
comes  for  his  first  examination. 

An  emulsion  is  prepared  consisting  of  bismuth  carbonate,  4  oz.  ;  sugar  of 
milk,  1|  oz.  ;  water  in  amount  sufficient  to  make  an  emulsion  which  is  not  thick. 

The  whole  drink  makes  less  than  a  tumblerful.  In  the  case  of  big  subjects, 
5  oz.,  or  even  6  oz.,  of  bismuth  carbonate  are  given,  with  a  correspondingly 
greater  amount  of  sugar  of  milk  and  water  ;  even  this  makes  no  more  than  a 
tumblerful.  The  water  should  not  be  quite  cold,  especiahy  in  winter.  I  have  not 
had  a  single  case  in  which  this  dose  has  produced  the  slightest  untoward  result. 

The  sugar  of  milk  in  this  "  standard  meal  "  has  a  threefold  function  :    (1) 


230 


EADIOGEAPHY 


to  make  a  satisfactory  emulsion^  (2)  to  increase  the  bulk  of  tke  meal^  and  (3)  to 
make  tlie  meal  pleasant.     In  some  cases  it  has  a  mild  laxative  effect. 

The  patient  is  first  examined  upright  on  a  revolving  saddle  seat  with 
canvas  back.  The  chest  is  examined^  first  in  the  anterior  view^  and  then  in  the 
right  anterior  obhque  view.  While  in  this  position  (R.A.O.)  the  patient  begins  to 
drink  the  bismuth  emulsion,  and  its  course  down  the  oesophagus  is  well  shown  ; 
if  this  appears  normal,  and  the  bismuth  begins  to  enter  the  stomach  at  once,  the 
patient  is  swung  round  to  the  anterior  position,  and  the  level  of  the  great  curva- 
ture of  the  stomach  is  noted  as  the  first  portions  of  bismuth  reach  it.  The  final 
level  of  the  great  curvature  is  lower  than  usual,  the  difl'erence  being  due  to  the 
weight  of  the  bismuth. 

After  the  vertical  examination  the  patient  is  examined  on  the  couch — supine, 
supine  after  lying  on  the  right  side,  prone.  All  details  regarding  the  size,  shape, 
and  position  of  the  stomach  and  duodenum  may  be  determined  at  this  examina- 
tion, and  accurate  observations  may  be  made  of  the  motor  activities  of  these 
organs.  Subsequently  the  bismuth  passes  through  the  small  and  large  intestines, 
and  enables  them  to  be  studied  to  great  advantage. — B.  M.  Journ.,  Nov.  22, 1913. 


Duodenal  Ulcer. — These  may  vary  in  character  from  the  simple  to  the 
perforating.  In  superficial  ulcer  the  emptying  time  of  the  stomach  is  normal 
or  decreased  in  contrast  to  the  delayed  emptying  in  cases  of  gastric  or  pyloric 
ulcer,  which  produce  a  spasm  of  the  pylorus,  the  stomach  generally  having 
the  hypertonic  form.  Penetrating  ulcer  of  the  duodenum  is  less  frequent,  and 
in  addition  to  the  symptoms  of  superficial  ulcer  has  the  characteristic  diver- 
ticulum outside  the  normal 
shadow  of  the  duodenum, 
which  persists  as  a  small 
bismuth  residue  after  the 
duodenum  is  empty.  The 
bismuth  shadow  is  therefore 
more  marked  in  duodenal 
ulcer,  because  a  characteristic 
of  all  ulcers  of  this  part  is  the 
retention  of  the  opaque  chyme 
for  a  longer  period  than 
normal,  as  the  result  of  a 
mild  stasis,  due  to  spasm  at 
the  duodeno- jejunal  junction. 
The  Jejunum  and 
Ileum. — These  may  be  sub- 
ject to  ptosis  when  a  general 
viscero-ptosis  is  present, 
though  this  is  not  common. 
Dilatation  of  the  ileum  may 
be  the  result  of  an  obstruc- 
tion at  the  ileo-csecal  valve  or 
in  its  vicinity,  when  there  is  a  delay  in  the  passage  of  food  to  a  marked  degree. 
Malignant  or  inflammatory  strictures  may  be  shown,  while  the  ileum  may 


Fig.  176. — Opaque  meal  iu  ileum  aud  cacum,  Mve  hours 
after  ingestion.  Stomach  was  completely  emptied. 
Note  the  contracted  ileum  entering  caecum,  dilata- 
tion behind  the  contraction,  and  stasis  of  food  in  small 
intestine.  Figs.  176  and  177  being  reiDroduced  from 
positives  the  position  of  the  csecum  is  reversed. 


PLATE  XLVII. — Stomach  showing  Obstruction  at  Pyloeds. 


a,  Stomach  showing  marked  delay  in  emptying  tiaie,  due  to  cicatricial  contraction  at  pylorus.  Diag- 
nosis, pyloric  ulcer,  confirmed  at  operation. 

&,  Showing  prolonged  delay  at  pylorus.  Note  irregular  outline  and  narrow  channel.  Diagnosis, 
■carcinoma  of  pylorus,  opei'able.     Confirmed  at  operation,  tumour  excised. 

c,  Marked  delay  in  emptying  of  stomach,  narrow  channel  connecting  stomach  and  duodenum. 
Diagnosis,  cicatricial  contraction  at  pylorus,  due  to  gastric  ulcer,  confirmed  at  operation. 


THE  SMALL  INTESTINE 


231 


attain  to  a  diameter  equal  to  that  of  the  colon,  the  obstruction  producing 
these  changes  being  generally  chronic  in  its  nature,  and  the  result  of  malig- 
nant or  tubercular  disease,  or  of  adhesions  or  contractions  due  to  chronic 
appendicitis,  or  other  inflammations  of  the  ca3cum  and  colon.  These  kinks 
have  been  described  by  Sir  Arbuthnot  Lane,  and  demonstrated  by  Dr. 
Jordan  by  means  of  the  bismuth  meal.  It  is  worthy  of  note  that  an  ileal 
kink  can  be  demonstrated  in  one  position  while  in  another  it  is  not  shown. 
These  kinks  should  always 
be  shown  with  the  patient 
in  the  erect  position  where 
possible.  In  a  true  kink 
the  intestine  should  be  dis- 
tended on  the  proximal  side 
of  the  kink,  and  there  should 
be  definite  evidence  of  nar- 
rowing at  the  point  of  ob- 
struction. Figs.  176  and 
177  show  a  condition  of 
ileal  stasis  which  was  defi- 
nitely diagnosed  by  the 
radiographic  examination. 
The  case  was  sent  as  a 
doubtful  condition  of  ap- 
pendix, with  a  suggestion 
that  the  condition  was  due 
to  the  presence  of  gallstones ; 
the  physician  in  attendance 
suspected  adhesions  in  the 
region  of  the  appendix.  The 
X-ray  examination  revealed  a  condition  of  Heal  stasis,  which  showed 
definitely  in  examinations  lasting  over  several  hours.  A  positive  diagnosis 
of  obstruction  due  to  adhesions  was  given.  The  surgeon  who  operated 
reported  as  follows  : 

"  The  ileum  was  kinked  by  a  fibrous  band  4  to  5  inches  from  the  ileo- 
csecal  valve  in  the  position  depicted  by  the  skiagram.  The  gall  bladder  was 
quite  free." 


Fig.  177. — Same  ease  at  a  later  stage,  ten  hours  after  iu- 
gestion.  The  C£ecum  contains  more  of  the  food.  The 
contraction  is  still  seen  at  the  entrance  to  csecnra,  and 
there  is  a  marked  degree  of  dilatation  and  stains  in  small 
intestine. 

Diagnosis  :  adhesions  in  neighbourhood  of  ileo-caecal  valve. 


Examination  of  the  Large  Intestine 

The  large  intestine  is  divided  into  (1)  Csecum  ;  (2)  ascending  colon  ;  (3) 
hepatic  flexure  ;  (4)  transverse  colon  ;  (5)  splenic  flexure  ;  (6)  descending 
colon  ;  (7)  sigmoid  flexure  ;  (8)  rectum.  The  anatomical  relations  of  these 
parts  should  be  clearly  understood. 

The  caecum  is  that  portion  of  the  colon  which  lies  below  the  ileo-csecal 
valve.  It  is  almost  entirely  surrounded  by  peritoneum,  and,  being  freely 
movable,  it  may  consequently  vary  in  position  in  different  subjects.     It  may 


232  EADIOGEAPHY 

be  found  in  tlie  pelvis  or  displaced  upwards.  The  appendix  is  sometimes 
seen  filled  with  bismuth,  and  may  be  the  seat  of  concretions  or  foreign  bodies. 
Pus,  the  result  of  an  inflammatory  process,  may  occasionally  be  seen. 

The  ascending  colon  extends  upwards  and  backwards,  into  the  iliac  fossa, 
and  reaches  nearly  to  the  liver,  where  it  forms  a  more  or  less  acute  angle. 


Splenic  flexure 

Hepatic  flexure    

Descending  colon 
Ascending  colon  ^^^^^^^  ^^^^^^^ 

Sigmoid  flexure 
Caecum  X.  ^^^^^  ^'^^'^^/'^^     Rectum 


Fig.  178. — Diagrammatic  representation  of  colon  filled  with  bismuth  food. 

The  hepatic  flexure,  together  with  the  first  portion  of  the  transverse 
colon,  is  frequently  ptosed,  drawn  forwards  and  downwards  ;  but  this  con- 
dition need  not  necessarily  give  rise  to  symptoms. 

The  transverse  colon  extends  from  the  hepatic  flexure  to  the  splenic 
flexure.  It  varies  greatly  in  position,  frequently  forming  a  well-marked 
loop  reaching  down  into  the  pelvis.  The  ascending  and  transverse  colons 
may  be  entirely  in  juxtaposition  when  the  latter  is  ptosed,  adhesions  some- 
times binding  the  two  together.  The  transverse  colon  forms  a  tense  band 
around  the  greater  curvature  of  the  stomach,  the  latter  thicd  of  the  transverse 
colon  rising  almost  perpendicularly  to  the  splenic  flexure,  where  it  forms  an 
acute  angle  with  the  descending  colon.  It  is  often  difficult  to  diflerentiate 
the  one  from  the  other  by  the  ordinary  radiograph.  Stereoscopic  radio- 
graphs are  useful  when  doubt  exists  as  to  the  condition  present. 

The  splenic  flexure  is  firmly  held  up  to  the  diaphragm  by  a  strong  ileo- 
colic ligament. 

The  descending  colon  extends  from  the  splenic  flexure  to  the  brim  of  the 
pelvis. 

The  sigmoid  flexure  is  variable  in  shape,  length,  and  position,  as  it  is 
attached  by  a  mesentery  which  varies  in  length. 

The  rectum  is  the  most  distensible  portion  of  the  colon. 


FOREIGN  BODIES  IN  THE  ALIMENTARY  CANAL  233 

Chronic  constipation  is  a  condition  which  frequently  calls  for  radiographic 
examination.  With  some  individuals  it  involves  observation  on  the  case  for 
three  or  four  days.  The  colon  is  frequently  low  in  the  pelvis,  and  it  may  be 
bound  down  by  adhesions. 

Tumours  of  the  large  intestine  may  cause  partial  or  complete  obstruction 
of  the  bowel.  The  double  method  of  giving  bismuth  by  the  mouth  and  in- 
jecting the  bowel  from  below  is  useful,  the  screen  examination  being  useful 
when  the  latter  method  alone  is  employed,  because  we  can  watch  for  the 
point  of  stricture.     Plates  may  be  taken  to  confirm  these  observations. 

Intestinal  Stasis. — Jordan  adds  to  the  knowledge  of  intestinal  stasis. 
He  associates  ileal  stasis  with  a  distended  duodenum,  especially  in  its  first 
part,  and  employs  a  special  technique  to  demonstrate  this  condition.  The 
jejunum  is  found  to  be  pulled  down  vertically,  forming  a  sharp  kink  with  the 
fixed  end  of  the  duodenum.  He  ascribes  this  to  the  direct  result  of  gravity 
upon  the  overloaded  lower  Ueal  coils.  The  obstruction  produced  by  the 
duodeno-jejunal  kink  is  sometimes  increased  by  tension  of  the  first  few 
inches  of  the  jejunum. 

Hertz  has  never  observed  true  stasis  of  the  duodenum,  except  in  cases  of 
organic  obstruction,  and  to  a  less  extent  in  extreme  gastroptosis,  in  which 
a  kink  may  occur  at  the  point  where  the  duodenum  is  fixed.  He  is  convinced 
that  kinking  plays  no  part  whatever  in  the  aetiology  of  duodenal  ulcer  ;  nor 
does  he  believe  that  ileal  kink  is  of  any  importance  in  the  causation  of  simple 
constipation.     He  shows  that  all  cases  of  constipation  fall  into  two  groups  : 

(1)  Delay  in  the  passage  through  the  colon,  defsecation  being  normal, 
"  intestinal  constipation." 

(2)  Dyschezia,  in  which  the  passage  through  the  colon,  is  normal,  but 
defsecation  is  inefficiently  performed. 

Foreign  Bodies  in  the  Alimentary  Canal 

Patients  are  frequently  sent  for  the  determination  and  subsequent 
localisation  of  foreign  bodies  in  the  alimentary  canal.  As  it  is  impossible 
to  indicate  in  what  positions  they  may  be  found,  an  examination  of  the 
entire  tract  is  necessary,  and  the  technique  will  be  described  in  some 
detail.  The  foreign  bodies  most  frequently  met  with  are  (1)  coins,  (2)  metal 
toys,  (3)  pins,  needles,  safety-pins,  (4)  nails,  (5)  teeth  and  artificial  plates, 
(6)  hair-pins,  (7)  enteroliths  and  gall  stones,  (8)  hair-balls. 

The  whole  alimentary  tract  from  the  pharynx  downwards  must  be 
examined,  especially  in  children.  For  the  pharynx  and  oesophagus  the  lateral 
position  gives  the  best  result.  It  is  often  difficult  to  locate  the  precise 
position  of  foreign  bodies  in  the  stomach.  In  doubtful  cases  a  small  quantity 
of  bismuth  food  may  be  given,  and  the  position  of  the  foreign  body  in  relation 
to  the  stomach  shadow  determined.  When  the  foreign  body  has  been  located 
in  the  stomach,  the  question  is  raised  as  to  whether  it  is  likely  to  pass  through 
the  pylorus  ;  the  necessity,  or  otherwise,  of  operation  is  often  decided  by 
the  radiograph,  and  depends  to  a  large  extent  on  the  nature  of  the  .foreign 


234  EADIOGKAPHY 

body  and  the  presence  of  urgent  symptoms.  A  foreign  body  which  causes  no 
symptoms  and  no  irritation  may  lie  in  the  stomach  for  weeks  and  ultimately 
be  passed.  The  passage  of  sharp-edged  or  pointed  bodies  may  be  greatly 
facilitated  by  administering  small  pledgets  of  moistened  cotton  wool.  The 
most  usual  spot  at  which  to  find  a  foreign  body  blocking  the  intestine  is  the 
ileo-caecal  valve.  When  a  foreign  body  has  been  located  in  the  alimentary 
tract  the  patient  should  be  screened  and  radiographed  at  regular  intervals. 
The  body  is  thus  kept  under  rigid  observation,  and  should  an  operation 
become  necessary  it  can  be  conducted  with  the  least  possible  delay.  Stereo- 
scopic radiographs  taken  immediately  prior  to  an  operation,  or  the  use  of 
X-rays  at  the  time  of  operation,  when  the  fluorescent  screen  may  be  used 
from  time  to  time,  will  be  found  useful  as  a  guide  to  the  surgeon.  By  the 
former  method  the  object  may  be  located  with  fair  accuracy  ;  by  the  latter 
method  the  operator  may  be  able  to  guide  his  instruments  to  the  foreign 
body.  Work  of  this  special  character  requires  to  be  carried  out  in  the  dark 
under  aseptic  conditions.  The  top  of  the  couch  must  be  made  aseptic  and 
the  fluorescent  screen  one  that  can  be  sterilised. 


PLATE  XLVIII.— Opaque  Enema  in  Colon. 

a,  Bismuth  enema,  showing  rectum,  pelvic  colon,  sigmoid  flexure,  splenic  flexure,  transverse  colon, 
hepatic  flexure,  and  caecum,  b.  Same  after  partial  evacuation.  The  two  plates  («  and  h)  were  taken  in  the 
horizontal  position  ;  when  the  patient  assumed  the  vertical  position  the  transverse  colon  formed  a  distinct 
loop  with  the  convexity  towards  the  pelvis,  c,  Marked  delay  in  descending  colon.  From  a  case  of  oId- 
struction  of  the  colon  on  left  side.  At  operation  the  colon  was  found  to  be  stretched  over  an  enlarged 
kidney,  which  contained  fluid. 


THE  X  RAY  EXAMINATION  OF  THE  URINARY  TRACT 

Radiography  has  now  attained  to  an  important  position  in  the  examina- 
tion of  the  urinary  tract.  From  a  diagnostic  point  of  view  the  information 
it  gives  is  of  the  highest  importance.  Every  case  of  suspected  disease  should 
be  thoroughly  examined  before  surgical  interference  is  decided  upon.  In 
cases  of  suspected  urinary  calculus  it  is  of  great  service  in  determining  (1) 
the  presence  of  a  stone  ;  (2)  its  position  and  size  ;  and  (3)  the  prognosis  and 
treatment  of  the  particular  case,  which  are  largely  determined  by  a  correct 
interpretation  of  the  radiographic  examination.  It  is,  however,  not  only  in 
cases  of  calculi  that  the  use  of  radiography  is  helpful.  Tuberculous  disease 
of  the  kidney,  ureter,  and  bladder  may  be  demonstrated,  and  in  other  dis- 
eases of  the  urinary  tract  the  use  of  X-rays  may  be  helpful.  Tumour  of 
the  kidney  and  bladder  can  be  shown  ;  cystic  disease  of  the  kidney  is  some- 
times demonstrable  ;  while  it  may  be  possible  to  show  chronic  cystitis 
when  phosphatic  deposits  occur  in  the  bladder.  Hypertrophy  of  the 
bladder  and  other  conditions  present  themselves  for  consideration,  when 
an  exhaustive  examination  of  the  organ  is  required. 

Technique 

A  thorough  examination  of  the  urinary  tract  should  be  undertaken  in 
all  cases  that  come  up  for  diagnosis.  If  stone  in  the  kidney  is  suspected,  it 
is  not  sufficient  to  examine  the  suspected  kidney  alone ;  the  whole  tract 
should  be  systematically  gone  over.  There  are  several  points  which  are  of 
the  greatest  importance  in  carrying  out  a  thorough  examination  of  the 
regions  suspected. 

A.  The  preparation  of  the  patient  is  the  first  item  for  consideration. 
In  all  cases  the  patient  should  be  prepared  in  the  same  manner  as  when  an 
operation  is  contemplated.  The  bowels  should  be  thoroughly  cleared  the 
evening  before  the  examination,  and  a  large  enema  should  be  administered 
just  before  the  patient  comes  to  the  X-ray  room.  The  selection  of  a  purga- 
tive is  of  importance.  Where  possible,  a  vegetable  purgative  should  be 
employed  in  preference  to  a  chemical  one,  as  the  latter  may  cause  shadows 
in  the  bowels,  superimposed  over  the  various  parts  of  the  urinary  tract. 
This  may  not  appear  to  be  of  any  importance,  but  we  have  to  bear  in  mind 
that  the  cause  of  the  trouble  may  be  a  very  small  calculus  in  the  ureter, 
and  if  it  is  to  be  shown,  it  is  of  the  greatest  importance  that  there  should 

235 


236  KADIOGEAPHY 

not  be  any  conflicting  evidence  in  the  nature  of  shadows  cast  by  small 
crystalline  bodies  in  the  intestines. 

B.  Examination  of  the  Patient. — There  is  considerable  latitude  in  the 
choice  of  a  position  for  the  examination  of  a  patient  suspected  of  having 
a  stone  in  the  urinary  tract.  It  will  be  well  to  describe  the  commoner 
methods  of  examination,  and  then  leave  it  to  the  operator  to  use  the  one 
he  is  best  acquainted  with. 

Screen  examination  of  the  patient  should  always  be  done  as  a  matter 
of  routine.  If  the  patient  is  placed  face  downwards  on  a  couch  with  the  tube 
underneath,  it  is  possible  to  examine  thoroughly  the  whole  region.  The 
fluorescent  screen  is  placed  on  the  patient's  back,  and  by  moving  the  tube 
about  underneath  the  table,  both  kidneys,  ureters,  and  bladder  may  be  care- 
fully examined.  By  this  method  of  examination  the  majority  of  stones  may 
be  seen,  also  the  size  and  position  of  the  kidneys,  the  motility  of  the  organs 
during  respiration,  and  the  size  and  position  of  the  bladder.  In  some  cases  it 
may  be  useful  to  distend  the  bladder  with  sterile  water  before  commencing  the 
examination.  In  cases  of  suspected  ureteric  stone,  an  opaque  catheter  may 
be  placed  in  the  ureter  from  the  bladder,  and  a  stone  may  be  located  by  this 
method.  Before  removing  the  patient  it  is  well  to  take  a  series  of  plates  in 
the  position  in  which  the  screen  examination  has  been  conducted.  This  is 
useful  as  a  permanent  record  of  the  screen  examination.  In  particular  cases 
a  tracing  may  be  made  of  the  exact  appearance  of  the  parts  under  examina- 
tion. In  these  circumstances  a  large  plate  may  be  employed.  Should  it  be 
desirable  to  radiograph  particular  areas  in  this  position,  the  tube  is  centred 
under  the  particular  part,  the  diaphragm  is  closed  down  to  a  suitable  aperture, 
a  plate  is  placed  on  the  back,  pressure  applied,  and  the  exposure  made. 

With  a  rapid  exposure  movement  of  the  organs  due  to  respiration  need 
not  interfere  with  the  result,  but  when  longer  exposure  is  necessary  some 
form  of  compressor  must  be  employed,  such  as  a  large  air  cushion  under  the 
patient,  and  pressure  from  above  on  the  plate  sufficient  to  steady  the  pa,rts, 
in  order  to  get  a  good  radiograph. 

The  second  method  employed  for  the  examination  is  to  place  the 
patient  on  his  back  ;  the  plate  is  placed  under  the  region  required,  and  the 
tube  is  operated  from  above.  In  this  method  the  screen  examination  is  not 
possible,  and  therefore  we  have  to  depend  entirely  upon  the  examination  of 
negatives  so  obtained.  Here  it  is  necessary  to  examine  the  whole  tract  in 
sections.  The  employment  of  some  form  of  compressor  is  of  value  in  this 
method.  Any  compressor  which  steadies  the  parts  and  arrests  respiratory 
movements  is  sufficient  for  the  purpose.  The  table  may  either  be  used  with 
the  tube  below  the  patient  for  screening  and  for  the  taking  of  radiographs, 
with  a  compressor  upon  the  plate  over  the  part  to  be  examined ;  or  by. turn- 
ing the  patient  on  the  back,  the  plate  can  be  placed  underneath,  and  the  tube- 
holder  with  a  large  extension  tube  brought  down  on  to  the  abdomen.  A  thick 
pad  of  cotton  wool  may  be  used  to  compress  still  further  the  abdominal  con- 
tents, this  also  serving  the  further  purpose  of  minimising  the  inconvenience 
of  great  pressure.     Many  elaborate  forms  of  apparatus  have  been  designed  ; 


TECHNIQUE  OF  KIDNEY  EXAMINATION 


237 


the  best  is  that  introduced  by  Dr.  Albers  Schoenberg  of  Hamburg.     Figs.  179 
and  180  show  the  essential  parts  of  the  apparatus,  and  its  use  in  practice. 


Fig.  179. — Couch  fitted  with  kidney  compressor. 

It  is  possible  by  this  method  to  get  small  accurate  pictures  of  the  kidneys, 
bladder,  and  ureters.      A  later  improvement  of  this   compressor  is  the 


Fig.  180. — X-Ray  couch  to  ilhistrate  method  of  compression. 

addition  of  a  stereoscopic  movement  to  the  apparatus,  thus  enabling  stereo- 
scopic pictures  of  the  urinary  tract  to  be  taken. 


238  RADIOGRAPHY 

In  all  cases  it  is  important  so  to  compress  the  parts  that  a  good  radio- 
graph is  obtained  with  long  or  short  exposures.  The  shorter  the  exposure 
the  better  is  the  result.  Where  possible,  the  patient  should  be  instructed 
to  hold  his  breath  during  the  exposure.  "WTien  this  does  not  exceed  20  or 
30  seconds,  it  is  possible  with  a  little  practice  for  the  patient  to  hold  his 
breath.  In  this  way  two  pictures  may  be  obtained,  (1)  at  the  end  of  in- 
spiration, and  (2)  at  the  end  of  expiration.  When  the  compression  is  perfect, 
it  is  possible  to  get  good  radiographs  with  exposures  of  one  or  two  minutes. 

The  next  important  point  in  the  taking  of  good  radiographs  lies  in  the 
management  of  the  X-ray  tube.  Here,  again,  a  great  deal  depends  upon 
the  operator  and  his  knowledge  of  the  apparatus  at  his  command.  Good 
pictures  can  be  obtained  with  almost  any  ordinary  apparatus.  It  is  not 
necessary  to  have  elaborate  installations  in  order  to  get  good  results.  Many 
of  our  radiographs  have  been  obtained  by;the  use  of  a  10-inch  coil,  a  mercury 
interrupter,  and  an  ordinary  X-ray  tube.  The  exposure  necessary  may 
vary  from  an  instantaneous  flash  to  five  minutes.  With  a  12-inch  coil,  a 
moto-magnetic  interrupter,  and  a  heavy  anode  Miiller  tube  it  is  possible  to 
get  all  the  necessary  detail  with  an  exposure  of  about  ten  seconds  or  less. 

The  controlling  factors  are  :  (1)  the  amount  of  current  passing  through 
the  X-ray  tube,  (2)  the  distance  of  the  tube  from  the  plate,  and  (3)  the  body 
weight  of  the  patient.  The  latter  factor  is  important  because  the  larger 
the  subject  the  further  away  from  the  plate  is  the  tube  likely  to  be. 

It  cannot  be  too  strongly  insisted  upon  that  the  controlling  factor  in 
all  radiographic  exposures  is  the  X-ray  tube  :  given  a  good  tube,  working 
at  its  proper  spark-gap  and  allowing  an  adequate  amount  of  current  to  pass 
through  it,  one  cannot  fail  to  get  accurate  results.  When  an  imperfect  tube 
is  used,  no  apparatus  will  give  the  proper  degree  of  penetration. 

When  a  considerable  amount  of  work  has  to  be  got  through,  it  is  well 
to  have  a  number  of  tubes  in  working  order.  If  possible,  the  same  type  of 
tube  should  always  be  employed,  and  they  should  be  kept  at  as  nearly  as 
possible  the  same  degree  of  vacuum.  It  is  possible  to  keep  a  tube  in  good 
working  order  by  never  allowing  it  to  run  too  long.  A  good  tube  will  keep 
in  working  order  for  months,  if  it  is  carefully  looked  after.  A  record  of  all 
exposures,  time,  quantity  of  current  used,  and  results  obtained  will  be 
helpful  in  practice,  for  then  one  gets  to  know  exactly  what  a  tube  is  capable 
of  doing.  Prolonged  screen  examinations  are  harmful  to  any  tube.  Where 
possible,  a  special  tube  should  be  employed  for  all  such  work.  In  practice, 
good  kidney  radiographs  have  been  obtained  with  all  varieties  of  tubes. 

The  development  of  the  plate  deserves  some  notice.  The  radiographer 
requires  to  have  a  special  knowledge  of  this  section  of  his  work.  Where 
possible,  in  all  important  cases  the  radiographer  should  develop  the  plate 
himself.  In  hospital  practice  this  is  not  possible,  but  there  one  generally 
has  a  nurse  or  photographer  who  looks  after  the  development.  In  any  case 
it  is  of  importance  that  the  person  who  develops  the  plate  should  have  some 
knowledge  of  the  conditions  under  which  the  radiograph  has  been  taken. 
The  developer  is  usually  one  containing  metol  and  hydroquinone,  though 


ANATOMICAL  RELATIONS  OF  THE  URINARY  ORGANS    239 

in  some  cases  pyro-soda  may  be.  employed.  In  a  properly  exposed  plate,  the 
development  is  generally  completed  in  about  five  to  ten  minutes. 

The  plate  is  fixed  in  the  ordinary  way.  It  should  be  allowed  to  fix  out 
in  the  dark  or  in  a  ruby  light,  though  the  negative  is  frequently  examined 
by  electric  light  before  it  is  thoroughly  fixed. 

We  have  not  seen  any  harmful  results  from  this  premature  examination, 
but  nothing  is  to  be  gained  by  a  hasty  examination,  and  it  is  evident 
that  harm  may  result,  so  a  good  rule  is  never  to  examine  a  plate  until  it 
has  been  allowed  to  fix  out  thoroughly. 


Anatomical  Relations  of  the  Urinary  Organs 

The  kidneys  are  a  pair  of  bean-shaped  organs,  each  measuring  about 
4|  inches  in  length,  2|  inches  in 
breadth,  and  1 1  inches  in  thickness, 
and  each  weighing  about  4|  ounces . 
They  lie  in  the  hypochondriac, 
epigastric,  and  umbilical  regions, 
and  are  placed  behind  the  peri- 
toneum in  a  kind  of  lymph  space 
in  the  fat-bearing  subperitoneal 
tissue,  opposite  the  last  dorsal 
and  three  upper  lumbar  vertebrae, 
the  right  usually  lying  about  half 
an  inch  lower  than  the  left.  The 
long  axis  of  each  is  directed  down- 
wards and  outwards.  Its  antero- 
external  or  visceral  surface  is 
directed  outwards  and  forwards, 
its  postero- internal  or  parietal 
surface  looking  backwards  and 
inwards.  Its  outer  border  repre- 
senting the  angle  of  junction  of 
its  two  surfaces  is  narrow  and 
convex  ;  its  inner  border,  look- 
ing obliquely  inwards,  forwards, 
and  a  little  downwards,  is  convex 
above  and  below,  but  slightly 
concave  in  its  middle  third,  and 
fissured  by  the  hilum.  The  upper 
extremity  is  rounded  and  sup- 
ports the  suprarenal  body,  which 
encroaches  also  upon  its  anterior 
surface  and  internal  border.  The 
lower  extremity,  also  rounded, 
lies    further    from   the    median 


Fig.  181. — Diagram  to  illustrate  the  "areas  "to  be 
examined  in  radiography  of  the  urinary  tract. 

Three  exposures  are  necessary  when  using  the 
compressor.  A,  kidney,  B,  ureter,  C,  pelvis.  Note 
that  each  area  should  overlap  the  one  above  it  if  the 
whole  tract  is  to  be  examined.  The  same  procedure 
has  to  be  followed  for  the  other  side.  By  using  a 
larger  extension  tube  the  whole  tract  maybe  examined 
with  three  exposures,  but  in  that  case  the  tube  must 
be  centred  over  the  middle  line  instead  of  to  either 
side. 

The  dotted  circles  represent  the  area  covered  by 
the  extension  tube  in  positions  A,  B,  and  C.  In 
region  marked  A  the  compressor  is  tilted  upwards, 
in  B  the  direction  is  at  right  angles  to  the  plate,  and 
in  C  the  compressor  is  tilted  downwards  towards 
the  feet  of  the  patient. 


240  KADIOGEAPHY 

plane  than  the  upper.  The  hilum  is  a  slit-like  aperture  in  the  middle 
of  the  inner  border  of  the  kidney,  bounded  in  front  and  behind  by  two 
prominent  lips.  It  forms  the  entrance  into  a  deep  depression  or  cavity, 
the  sinus,  at  the  bottom  of  which  are  (1)  the  renal  papillae,  perforated 
by  the  openings  of  the  secreting  tubules  ;  (2)  the  apertures  transmittiag 
the  vessels  and  nerves  to  the  organ  ;  and  (3)  the  attachments  of  the  "  calices  " 
of  the  main  duct,  each  embracing  one  or  two  of  the  papillae.  The  kidney  may, 
in  fact,  be  regarded  as  a  hollow  organ. 

Relations. — In  front  of  the  right  kidney  are  the  right  lobe  of  the  liver, 
the  second  stage  of  the  duodenum,  the  hepatic  flexure  of  the  colon,  a  branch 
of  the  colica  dextra  artery,  and  more  or  less  of  the  parietal  peritoneum,  on 
the  inner  side  of  the  latter.  In  front  of  the  left  kidney  are  the  stomach  (with 
the  peritoneum  of  the  lesser  sac),  the  splenic  artery,  the  pancreas  and  the 
splenic  vein,  the  splenic  flexure  of  the  colon,  the  parietal  peritoneum,  a 
branch  of  the  colica  sinistra  artery,  and  the  spleen  (at  the  outer  border). 
Behind  both  kidneys  are  the  diaphragm,  the  psoas  and  the  anterior  lamella 
of  the  transversalis  tendon  (covering  the  quadratus  lumborum),  with  the  re- 
spective fasciae  of  those  muscles  and  the  last  dorsal,  the  ilio-hypogastric  and 
the  ilio-inguinal  nerves.  The  diaphragmatic  area  is  generally  larger  on  the 
right  side,  and  may  be  considerably  increased  on  either,  when  the  external 
arcuate  ligament  passes  to  the  second  lumbar  process  instead  of  the  first. 

The  ureters  are  about  a  foot  long,  and  lie  in  a  sheath  of  subperitoneal 
tissue  over  the  psoas  muscles,  passing  behind  the  spermatic  vessels,  and  after 
crossing  the  common  or  external  iliac  artery,  disappear  into  the  pelvis, 
where  they  can  be  traced  to  the  bladder.  The  right  ureter  runs  behind  the 
second  stage  of  the  duodenum,  and  lies  close  to  the  inferior  vena  cava.  In 
the  female,  both  ureters  approach  the  sides  of  the  cervix  uteri,  and  lie  in 
contact  with  the  upper  part  of  the  vagina,  crossing  it  obliquely  to  reach  the 
base  of  the  bladder.  The  proximal  extremity  of  each  ureter  begins  with 
eio-ht  or  nine  short  tubes  called  calices,  which  surround  the  renal  papillae 
at  the  bottom  of  the  sinus.  These  join  each  other,  with  or  without  the 
intervention  of  short  passages  called  infundibula,  to  form  usually  two  tubes, 
the  upper  and  lower  pelves,  and  the  union  of  the  two  pelves  constitutes  the 
common  pelvis  renales,  which  generally  narrows  to  the  size  of  a  goose  quill, 
and  becomes  the  ureter  proper.  The  ureters  pierce  the  bladder  at  the 
junction  of  the  posterior  or  lateral  walls,  about  an  inch  and  a  half  above  the 
base  of  the  prostate.  The  left  ureter  is  contained  in  the  root  of  the  posterior 
false  ligament  of  the  bladder  (or  in  part  of  the  broad  ligament  in  the 
female),  and  can  be  traced  beneath  the  peritoneum  to  its  entrance  into  the 
fundus  of  the  bladder. 


Diseases  of  Urinary  Tract 

In  order  to  make  a  diagnosis  from  negatives  of  the  urinary  tract  in 
disease,  it  is  necessary  for  the  radiographer  to  be  famihar  with  the  appearance 
of  good  normal  negatives  from  the  region  of  the  kidneys,  ureters,  and  bladder. 


'^W. 

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W"'" 

'~'~^i&^       .._ 

^ 

1^ 

PLATE  XLIX.— Urinary  Calculi. 


a,  Calculi  in  kidney. 
Calculi  in  kidney.     (Radiograph  by  C.  Thurston  Holland.) 
c,  FiKcal  mass  in  kidney  area  simulating  calculus. 


CALCULUS  IN  THE  KIDNEY 


241 


This  knowledge  can  only  be  acquired  by  regular  practice,  though  it  is  possible 
to  demonstrate  the  essential  points  by  means  of  a  series  of  radiographs.  A 
good  radiograph  of  the  kidney  area  should  show  the  outline  of  the  organ, 
and  should  cover  the  whole  of  the  kidney.  In  order  to  get  the  whole  of  the 
area,  it  is  necessary  to  get  the  two  lower  ribs  in  the  picture. 

Bearing  in  mind  the  normal  appearances  of  the  urinary  tract,  we  now 
proceed  to  a  consideration  of  the  abnormalities  which  may  be  met  with  in 
the  investigation  of  diseases  of  the  urinary  organs.  Before  considering  those 
diseases  in  order,  it  is  necessary  to  consider  some  of  the  conditions  which, 
when  met  with,  are  apt  to  mislead  the  observer  and  cause  errors  of  diagnosis. 
Those  are  numerous  and  ever  increasing  in  number  as  fresh  cases  are  recorded. 

(1)  Faecal  matter  in  the  intestines.  This  is  a  common  cause  of  mistake 
in  diagnosis,  but  if  the  necessary  preparatory  measures  recommended  are 
carefully  carried  out  this  cause  should  never  occur. 

Plate  XLIX.,  Fig.  c,  illustrates  an  instance  of  this  kind,  where  a  large 
shadow  is  seen  in  the  pelvis  of  the  kidney,  which  might  easily  have  been 
diagnosed  as  a  large  stone.  A  second  radiograph,  taken  tw^o  days  later  after 
free  purgation,  shows  the  mass  lower  down  in  the  colon.  The  point  which  led 
to  a  diagnosis  of  faecal 
matter  was  the  loaded 
condition  of  the  colon 
over  the  opposite  kid- 
ney region. 

(2)  Foreign  bodies 
in  the  intestine  may 
be  mistaken  for  cal- 
culus. 

(3)  Enlarged  and 
calcified  mesenteric 
glands  are  another 
element  leading  to 
error  in  urinary 
diagnosis. 

(4)  The  case  of 
foreign  bodies  in  the 
kidneys,  introduced 
at  the  time  of  a  pre- 
vious operation,  must 
not  be  overlooked. 

(5)  Concretions 
in  the  appendix  have  been  mistaken  for  ureteral  calculi. 

(6)  Phleboliths  are  another  common  cause  of  mistaken  diagnosis. 
These  are  found  low  down  in  the  pelvis,  and  may  be  mistaken  for  stones 
in  the  ureter. 

Urinary  Calculi. — 1.  In  the  Kidney. — Stones  may  be  found  in  any 
part  of  the  kidney.     The  most  frequent  position  is  in  the  pelvis  or  calices. 

16 


Fig.  182. — Kidney  area,  showing  stone  in  right  kidney. 
(a)  inner  edge  of  kidney  ;  (b)  stone  ;  (c)  edge  of  psoas  muscle. 
The  tube  has  been  centred  over  the  middle  line.      Both  kidney  areas 
are  in  the  picture. 


242 


KADIOGKAPHY 


They  vary  in  size  and  composition.  The  commoner  stones  are  the  oxalates 
and  the  uric-acid  and  phosphatic  varieties,  the  uric-acid  calculi  being  the 
most  frequently  met  with.  A  rarer  variety  is  composed  of  cystin.  The 
great  majority  of  kidney  stones,  however,  are  of  mixed  composition.  It  is 
very  rare  to  get  a  pure  uric-acid  calculus.  The  shadows  thrown  by  stones 
vary  in  density,  the  oxalic  variety  giving  the  densest  shadow,  the  phos- 
phatic next,  and  lastly  the  uric-acid  variety.  Stones  may  vary  in  shape. 
Large  stones  have  been  found  to  occlude  the  pelvis,  and  to  have  branched 
ramifications,  filling  up  the  calices.  Small  calculi  may  be  found  in  the  sub- 
stance of  the  kidney,  and  vary  in  size  from  minute  bodies  to  the  size  of  a 
hazel  nut.     When  many  calculi  are  present  they  are  usually  faceted. 

Urinary  Calculi. — 2.   In  the  Ureter. — A  small  stone  wiU  find  its  way 
down  the  ureter  into  the  bladder.     The  passage  of  a  stone  is  usually  accom- 

Patient  aged  27  years.  At  age  of  4  an  attack  of  acute 
pain  ill  the  left  renal  region  followed  by  hsematuria.  Many 
similar  attacks  followed,  but  were  not  always  accompanied 
by  hfematuria.  At  age  of  12  a  skiagram  was  taken  and 
calculus  in  the  left  kidney  was  diagnosed  but  no  operation 
advised.  Between  that  time  and  the  date  I  saw  her  attacks 
of  pain  had  recurred  with  considerable  frequency,  and  after 
leaving  school  she  followed  no  occupation  till  the  age  of  22, 
when  she  became  a  barmaid.  Had  often  to  return  home  on 
account  of  pain.  During  1910  several  severe  attacks  of 
hsematuria. 

On  Examination. — Left  kidney  not  palpable  ;  in  the  region 
of  the  left  ureter  a  long,  hard,  sausage-shaped  tumour  can  he 
felt  extending  from  the  lower  pole  of  the  kidney  to  the  pelvic 
brim  ;  per  rectum  a  similar  mass  can  be  felt  in  the  region  of 
the  termination  of  the  left  ureter.  Its  lower  extremity  is 
pointed  and  can  be  moved  slightly  from  side  to  side. 

Skiagram  showed  no  shadow  in  left  kidney  ;  in  region  of 
left  ureter  a  continuous  shadow  extending  from  the  pelvis  of 
the  kidney  to  the  brim  of  the  true  pelvis,  and  below  this  a 
second  shadow  extending  to  the  entrance  of  the  ureter  into 
the  vesical  wall.  The  calculi  appear  to  be  articulated  with 
one  another  at  the  pelvic  brim. 

Ci/stoscopic  Ezaminaiion. — Twenty  minutes  after  injection 
of  imligo  carmine.  Right  ureteral  orifice  normal  and  excreting 
jets  of  blue  urine  vigorously.  Left  orifice  situated  on  a  mound- 
like elevation.  No  blue  urine  issuing,  but  an  occasional  feeble 
jet  of  blood-stained  fluid.  Ureteral  catheter  enters  orifice 
easily,  but  is  arrested  at  a  point  ^  inch  from  the  opening. 

Operation,  17th  March  1911. — Kidney  exposed  and  found 
to  be  hydronephrotic.  No  calculi  in  kidney.  Ureter  much 
dilated  and  containing  a  calculous  cast  which  extended  from 
renal  pelvis  to  below  the  brim  of  true  pelvis.  Below  this  a  second 
calculus  articulating  with  the  first  and  reaching  as  far  as  lower 
end  of  ureter.  The  lower  calculus  was  removed  with  some 
difficulty  owing  to  the  ufiper  end  hitching  below  the  pelvic 
brim.  Ureter  considerably  torn  owing  to  its  friability,  neph- 
rectomy and  ureterectomy.  Recovery  uneventful, 
shows  that  its  apex  is  formed  by  a  small  renal  calculus,  and 
us  has    been    formed   by  the    deposit    of   successive    layers   of 


Fig.  183. — Stone  in  ureter. 
(By  kind  permission  of  Mr. 
Collinson.  Radiograph  by  Dr. 
Rowden. )  The  calculi  shown  in  the 
radiograph  are  remarkable.  The 
notes  of  the  case  are  here  given. 

A  section  of  the  lower  calculus 
that    the    remainder    of   the   calcul 
phosphates. 


panied  by  symptoms,  the  chief  of  which  is  renal  colic.  This  may  be  severe 
in  character,  and  does  not  bear  an  exact  relationship  to  the  size  of  the  stone. 
A  small  irregular  stone  may  give  rise  to  very  severe  renal  colic  ;  a  larger 
smooth  stone  may  pass  more  readily  down  the  ureter,  and  not  give  rise  to 
marked  symptoms.     The  stone  in  its  passage  down  the  ureter  may  be 


PLATE  L.— TuBEECULOSis  of  Kidney  and  Mesenteric  Glands. 

a,  Calcareous,  caseous  mass  in  kidney  region,  the  result  of  tuberculosis,  confirmed  at  operation. 

h,  Calcareous  patches  in  left  kidney  area,  probably  due  to  healed  tubercle  of  the  kidney  ;  the  larger  shadow 
might  easily  be  a  calculus. 

c,  Calcified  mesenteric  glands.  The  appearance  of  these  shadows  might  lead  to  a  mistaken  diagnosis  of 
stones  in  the  kidney. 


CALCULI  IN  THE  URETERS  AND  BLADDER 


243 


arrested  at  any  part  of  its  course,  the  commonest  seat  of  arrest  being  in  the 
pelvis,  close  to  the  entrance  to  the  bladder.  The  symptoms  may  be  marked 
according  to  the  degree  of  occlusion  caused  by  the  stone.  A  stone  which 
completely  blocks  the  ureter  leads  to  an  accumulation  of  urine  in  the  portion 
of  ureter  above  the  seat  of  occlusion  and  in  the  kidney.  When  the  occlusion 
is  not  complete,  the  passage  of  urine  is  not  completely  arrested,  and  the  more 
distressing  symptoms  may  be  absent.  It  is  interesting  to  note  that  a  stone 
may  remain  in  the  ureter  for  many  months,  and  only  occasionally  give  rise 
to  symptoms  of  pain,  hsematuria,  etc.  An  examination  of  the  urine  for  pus 
and  epithelial  cells  may  help  to  determine  the  presence  of  a  stone  in  the 
ureter.  In  several  cases  we  have  watched  the  passage  of  a  small  ureteric 
calculus  down  the  ureter,  and  in  one  instance  repeated  examinations  showed 
that  the  stone  was  slowly  travelling  down  to  the  bladder  ;  the  symptoms 
were  not  severe,  attacks  of  colic  at  intervals  of  months  indicating  the  progress 
of  the  stone.  Ultimately  it  was  passed  into  the  bladder  and  voided  in  the 
urine.  This  is  by  no  means  an  uncommon  occurrence,  and  should  be  kept 
well  in  mind  when  we  have  to  consider  the  question  of  operative  interference 
in  a  case  where  the  presence  of  a  stone  has  been  demonstrated  in  the  course 
of  the  ureter.  If  the 
symptoms  are  not 
acute,  all  small 
ureteric  calculi  should 
be  given  every  facility 
to  pass  into  the 
bladder  before  a 
serious  operation  is 
contemplated. 

What  might  be 
termed  a  migratory 
stone  in  the  ureter 
is  well  illustrated 
by  a  case  occurring 
in  the  practice  of  Dr. 
Thurston  Holland  of 
Liverpool,  where  a 
large. stone  was  found 
to  occupy  a  position 
in  the  lower  ureter 
and  pelvis  of  the 
kidney  alternately. 
At  the  operation  it  was  found  that  the  ureter  was  dilated  to  an  enormous 
extent. 

Urinary  Calculi. — 3.  In  the  Bladder. — A  vesical  calculus  may  be 
formed  of  almost  any  of  the  urinary  deposits  met  with,  and  each  has  its  own 
characteristics. 

(a)  The  uric-acid  calculus  is  usually  oval  in  shape  and  flattened,  and  of 


Fig.  184. — Large  stone  iu  the  bladder. 
The  variations  in  the  density  of  the  stone  are  well  shown. 


244  EADIOGEAPHY 

variable  density.  On  section  it  is  distinctly  laminated  with  a  smooth, 
or  slightly  undular  surface  of  a  brownish  colour.  It  may  be  crusted  with 
phosphatic  material.  A  pure  uric-acid  calculus  gives  a  faint  shadow  radio- 
graphically. 

(6)  The  urate  of  ammonium  calculus  is  of  a  similar  structure,  but  of 
lighter  colour. 

(c)  Oxalate  of  lime  calculus  is  a  rough  irregular  body,  not  infrequently 
tuberculated  or  even  spiculated.  It  is  extremely  hard  and  dense,  of  a 
reddish-brown  colour,  or  sometimes  black,  owing  to  admixture  with  blood. 
It  is  rarely  of  great  size,  on  account  of  the  irritation  caused  by  its  presence 
and  its  slowness  of  growth. 

(d)  A  pure  phosphatic  calculus  is  somewhat  rare,  but  any  stone  or  foreign 
body  is  certain  to  become  coated  with  a  phosphatic  deposit  when  chronic 
cystitis  has  resulted  in  alkaline  decomposition  of  the  urine. 

(e)  Cystin  forms  the  base  of  a  rare  calculus. 

(/)  Xanthine  or  xanthic  oxide  is  occasionally  met  with,  but  is  very  rare. 
The  presence  of  a  calculus  in  the  bladder  is  readily  shown  by  X-ray  examina- 
tion. Such  an  examination  is  most  helpful  to  the  surgeon,  for  it  demonstrates 
the  presence  of  stone  or  stones,  the  number  of  the  calculi  present,  and  to 
some  extent  the  position. 

In  all  cases  of  urinary  calculi  several  examinations  should  be  made, 
unless  very  definite  evidence  is  obtained  on  the  first  occasion.  No  opinion 
negative  or  positive  should  be  given  without  at  least  one  confirmatory 
examination,  and  where  an  operation  is  contemplated  a  final  radiograph 
should  be  taken  immediately  prior  to  the  operation.  In  some  cases,  indeed, 
this  should  be  done  even  while  the  patient  is  imder  the  anaesthetic.  In  im- 
portant cases  this  may  be  done  and  the  plate  developed ;  the  surgeon  will 
then  have  a  very  definite  guide  for  reference  during  the  actual  operation. 

Tuberculous  Disease  of  the  Kidney  is  of  comparatively  frequent 
occurrence,  and  is  one  of  the  first  conditions  to  be  suspected  when  radiographic 
examination  has  failed  to  show  the  presence  of  a  stone.  It  may  occur  in 
one  of  three  forms  : — (a)  Acute  general  tuberculosis,  when  miliary  tubercles 
are  found  studding  the  organs.  Kadiography  is  rarely  of  much  service  in 
this  variety.  (6)  Ascending  tuberculosis  may  arise  from  a  similar  affection  of 
the  bladder.  The  mucous  membrane  of  the  ureter  becomes  thickened  and 
the  pelvis  and  calices  also  become  affected.  On  clinical  examination  enlarge- 
ment of  the  kidney  is  the  next  manifestation.  Radiography  may  be  helpful 
in  demonstrating  the  enlarged  kidneys  ;  and  when  caseous  matter  is  present 
or  abscesses  form,  the  negative  may  show  these  affections,  (c)  Primary 
tuberculosis  of  the  kidney  is  generally  unilateral,  and  commences  as  a  deposit 
of  tubercle  in  the  cortex  or  at  the  base  of  one  of  the  pyramids  ;  a  caseous 
mass  forms,  which  may  extend  widely,  causing  disintegration  of  the  kidney 
substance. 

Enlarged.  Movable  Kidney. — This  may  be  {a)  simple,  or  (6)  compli- 
cated by  calculi.  The  kidney  may  be  found  to  be  freely  movable,  and  may 
be  palpable.     Screen  examination  will  reveal  its  position  and  the  amount  of 


PLATE  LI. — Ukinary  Calculi  and  Gallstones. 


a,  Small  calculus  in  bladder.     Phlebollths  on  right  and  left  sides  of  pelvis. 
h,  Gallstones  in  gall  bladder.     Plate  on  anterior  aspect  of  abdomen. 
Two  gallstones  ;  note  position  below  the  kidney  shadow.     (Radiograph  by  C.  Thurston  Holland.) 


PLATE  LII. — Kidneys,  Ureter,  and  Bladder. 

a,  Collargol  in  pelvis  of  kidney  and  ureter.     (Radiograph,  by  C.  Thurston  Holland.) 

b,  Calculus  in  ureter. 

c,  Barium  injection  of  bladder  to  show  diverticulum,  opaque  bougie  in  ureter. 


TUMOURS  OF  THE  KIDNEYS  245 

mobility.  A  stone,  if  present,  is  readily  demonstrabJc.-.  1'he  following  illus- 
trates a  case  of  this  kind  :  A  lady  about  thirty-five  years  of  age  complained 
of  a  constant  pain  in  the  right  side.  Examination  revealed  a  freely  mov- 
able kidney  on  the  right  side,  the  lower  pole  being  very  tender  and  hard. 
Radiographic  examination  showed  the  enlarged  organ  displaced  downwards. 
Two  definite  shadows  in  the  cortex  indicated  the  presence  of  two  small  stones. 
A  large  irregular  shadow  in  the  lower  pole  led  to  some  discussion  as  to  its 
nature.  It  was  evidently  in  the  kidney  or  attached  to  it,  because  it  moved 
with  the  kidney.  A  diagnosis  of  stones  in  the  kidney  was  made.  At  the 
operation  two  small  calculi  were  removed.  The  appendix  was  found  to  be 
distended,  and  in  all  probability  this  may  have  accounted  for  the  larger 
shadow.  The  patient  has  not  been  examined  since  the  operation,  but  it  vnW 
be  interesting  to  note  the  appearance  of  the  parts  when  an  opportunity 
occurs.  Thickened  capsule  of  the  kidney  may  give  shadows  suggestive  of 
stone,  especially  when  the  pelvis  is  thickened. 

Tumours  of  the  Kidney. — These  are  numerous  and  worthy  of  notice, 
the  tumour  being  either  simple  or  malignant.  The  general  characteristics 
are  as  follows :  A  swelling  is  noticed  in  the  loin,  shaped  more  or  less  like 
the  kidney,  a  notch  being  occasionally  felt  on  the  inner  border,  and  the 
outer  margin  being  rounded.  The  flank  is  dull  on  percussion,  the  passage  of 
the  colon  in  front  of  the  kidney  occasionally  giving  a  note  of  resonance  over 
its  anterior  surface.     The  mass  moves  slightly  on  respiration. 

Simple  Tumours. — Cystic  disease,  which  may  be  congenital  or  acquired, 
is  the  usual  form  of  simple  tumour.  It  is  not  infrequently  bilateral  when 
congenital.  Especially  when  congenital,  the  kidney  is  enlarged  and  occupied 
by  cysts  of  various  size,  but  rarely  exceeding  that  of  a  cherry.  They  are 
lined  with  epithelium,  which  is  generally  flattened,  and  fiUed  with  a  limpid 
fluid  containing  urea  and  perhaps  cholesterine.  The  pelvis  remains  im- 
afTected  until  the  later  stages  of  the  disease.  Generally  the  whole  kidney  is 
affected,  and  may  attain  enormous  dimensions.  But  occasionally  the  growth 
is  limited  to  one  part  of  the  organ.  The  early  symptoms  are  simply  those  of 
pressure,  but  at  a  later  stage  the  secretion  of  urine  is  interfered  with  to  such 
an  extent  as  to  produce  uraemia.  The  radiographic  examination  of  this 
condition  is  unsatisfactory.  In  the  majority  of  cases  the  enlargement  of  the 
organ  may  be  shown,  and  occasionally  variations  in  the  density  of  the  kidney 
shadow  may  lead  one  to  suggest  the  presence  of  fluid  in  the  organ.  One 
generally  excludes  the  presence  of  stone  in  such  cases,  and  when  the  symp- 
toms are  not  such  as  to  suggest  acute  hydronephrosis  or  tuberculosis  then  the 
presence  of  fluid  showing  in  the  radiograph  may  enable  one  to  give  a  diagnosis 
of  cystic  kidney.  We  have  examined  a  number  of  cases  of  enlarged  kidney 
with  no  active  symptoms,  and  in  several  a  diagnosis  of  cystic  disease  of  the 
kidney  has  been  arrived  at,  and  confirmed  on  operation.  One  case  under 
observation  at  the  present  time  in  an  adult  shows  shadows  of  considerable 
size  in  both  loins.  The  patient  has  had  active  hsematuria,  presumably  the 
result  of  traumatism. 

Malignant  Disease  of  the  kidney  may  be  divided  into  : 


246  RADIOGRAPHY 

(1)  The  sarcomata  of  infants,  which  is  often  congenital,  but  may  be 
acquired  within  the  first  few  years  of  life.  They  grow  to  a  great  size,  and  may 
affect  both  organs.     Pain  and  hsematuria  are  absent. 

(2)  The  sarcomata  of  adults  occur  most  commonly  between  the 
thirtieth  and  fiftieth  years  of  life,  and  are  of  the  spindle-celled  variety. 

(3)  Carcinoma  of  the  kidney  is  an  uncommon  form  of  tumour.  It  is 
frequently  associated  with  the  presence  of  a  varicocele,  the  results  of  pressure 
from  carcinomatous  glands. 

(4)  Hypernephroma  arising  from  suprarenal  tissue  is  not  uncommon. 
Various  Cystic  Conditions  of  the  kidney  may  be  noted  in  addition  to  the 

general  cystic  disease  already  mentioned  : 

(a)  Hydatid  disease  afiects  the  kidney,  as  any  other  organ  of  the  body. 

(6)  Dermoid  cysts  have  also  been  found. 

(c)  Serous  cysts  are  occasionally  met  with. 

One  point  is  worthy  of  note  in  connection  with  the  systematic  examina- 
tion of  the  kidneys.  The  attention  directed  to  the  suspected  kidney  should 
not  lead  the  observer  to  ignore  the  other  and  presumably  sound  organ.  When 
it  is  definitely  settled  that  one  organ  is  diseased  and  an  operation  is  decided 
upon,  the  radiographer  should  proceed  to  demonstrate  the  presence  of  the 
other  organ  and  should  satisfy  himself  that  its  condition  is  normal.  It 
occasionally  happens  that  a  patient  comes  up  for  examination  who  has  been 
operated  upon  before.  The  presence  of  a  scar  in  the  loin  suggests  an  opera- 
tion, but  the  majority  of  patients  have  no  actual  knowledge  of  what  has  been 
done.  The  radiographer  has  then  to  demonstrate  the  presence  or  absence  of 
the  kidney  on  the  side  which  has  been  operated  upon.  If  he  finds  the  kidney 
has  been  removed,  then  he  proceeds  to  examine  the  other  kidney.  Should 
the  patient  have  symptoms  of  disease  on  this  side,  the  knowledge  that  one 
kidney  has  been  already  removed  will  be  of  great  service  to  the  surgeon. 

Occlusion  of  the  Ureter. — The  ureter  may  be  occluded  as  a  result  of 
cicatricial  changes  in  its  walls  following  laceration  from  the  passage  of  a 
calculus.  A  simple  stricture  of  the  ureter  may  result.  A  calculus  may 
completely  block  the  ureter,  and  lead  to  acute  symptoms  of  obstruction. 

The  ureter  may  be  obstructed  by  pressure  in  any  part  of  its  course  ; 
tumours  of  neighbouring  organs  occasionally  lead  to  an  obstruction.  Tumours 
in  the  pelvis  may  gradually  occlude  both  ureters  and  lead  to  suppression  of 
urine.  All  these  conditions  may  be  met  with  in  the  examination  of  the 
urinary  tract,  and  should  be  well  borne  in  mind.  A  negative  diagnosis  of 
stone  may  be  made,  and  in  some  cases  the  cause  of  the  obstruction  may  be 
determined  by  a  careful  examination. 

In  doubtful  cases  of  kidney  disease  there  are  other  methods  of  examina- 
tion which  may  be  regarded  as  supplementary  to  the  methods  described.  The 
examination  may  be  rendered  more  valuable  and  absolutely  diagnostic 
in  suspected  stone  in  the  ureters,  or  when  shadows  are  shown  in  the  line  of 
the  ureters,  by  the  passage  of  opaque  bougies  into  the  bladder  and  ureter.  A 
radiograph  taken  should  show  the  bougie  in  the  canal,  and  the  relationship 
of  the  shadows  to  it.     A  second  method  in  doubtful  cases  is  to  inject  into 


PLATE  LIU. — Dermoid  Cyst  in  Pelvis. 


a  and  h,  Eadiograph  of  pelvis  showing  cyst. 

c  and  d,  Radiograph  of  cyst  after  removal  by  operation.      Note  the  teeth  in  the  cyst. 

f,  Photograph  of  cyst  after  removal. 

/,  Pi,adiograph  of  a  heart  showing  atheroma  of  coronary  arteries. 


TECHNIQUE  OF  COLLARGOL  INFECTION  247 

the  ureter  and  pelvis  of  the  kidney  a  solution  of  collargol,  it  being  possible 
to  demonstrate  dilatation  of  the  ureter  and  calices  of  the  kidney  by  this 
method.  The  existence  of  hydronephrosis  of  the  kidney  is  rendered  visible 
when  the  kidney  has  been  injected,  while  kinks  and  contractions  of  the  ureter 
may  also  be  shown  by  this  method. 


Technique  of  the  Examination  of  the  Urinary  System 
with  Collargol  Solution 

Position  of  the  Patient. — The  recumbent  position  is  the  best,  the 
patient  lying  on  a  hard  couch  ;  anaesthetics  are  not  employed  as  a  rule. 

Demonstration  of  the  Ureter. — There  are  several  ways  in  which 
the  ureter  can  be  demonstrated  : 

(1)  By  the  use  of  a  silver  stylet  enclosed  in  an  ordinary  catheter. 

(2)  By  the  use  of  catheters  or  bougies  impregnated  with  bismuth. 

(3)  By  the  use  of  specially  prepared  ureteral  bougies. 

(4)  By  the  use  of  collargol  solution. 

Nos.  (3)  and  (4)  are  those  usually  employed,  and  of  these  two  the  collargol 
method  is  the  more  certain.  An  ordinary  catheter  in  situ  is  filled  with  col- 
largol, and  radiographed,  or  the  radiogram  is  taken  while  the  collargol  is 
trickling  down  the  ureter  from  the  pelvis  of  the  kidney. 

Strength  of  the  Solution  employed. — Solutions  of  from  3  to  20  per 
cent  are  employed,  but  10  per  cent  is  the  most  usual  strength.  The  strength 
employed  should  be  selected  according  to  (1)  the  stoutness  of  the  patient ; 
(2)  the  degree  of  hydronephrosis,  if  this  be  present.  A  weak  solution  should 
be  employed  if  an  abnormal  shadow  has  been  detected  in  the  renal  pelvis, 
for  should  there  be  a  stone  in  the  pelvis  or  calix,  and  too  strong  a  solution  be 
used,  it  is  probable  that  the  collargol  shadow  may  obliterate  the  one  of  the 
calculus. 

Dangers  arising  from  the  Use  of  Collargol. — (1)  Cases  of  sepsis  have  been 
reported  ;  (2)  areas  of  necrosis,  infarct,  and  cast  formation  have  been  known 
after  the  distension  of  the  pelvis  under  high  pressure.  Strassmann  has 
carefully  investigated  these  points,  and  has  come  to  the  conclusion  that  the 
injection  of  collargol  in  proper  quantity  and  under  moderate  and  careful 
pressure  causes  no  harmful  results. 

Sacculi  of  the  Bladder. — These  may  be  shown  radiographically,  but 
solutions  of  barium  sulphate  are  used  instead  of  collargol  on  account  of  the 
cost.  Two  parts  of  barium  sulphate  are  suspended  in  ten  parts  of  oleum 
amygdalae  dulcis,  and  this  suspension  corresponds  well  with  collargol  solution 
in  density  of  shadow  produced. 


248  KADIOGEAPHY 


Congenital  Malformations 

All  varieties  are  met  with  in  the  routine  examination  by  X-rays. 
Valuable  information  may  be  obtained  as  to  the  presence  of  these  abnor- 
mahties,  their  form  and  extent,  and  hght  is  thrown  upon  them  from  the 
operative  point  of  view. 

It  is  impossible  to  give  a  complete  account  of  the  departures  from  the 
normal  which  occur  in  all  parts  of  the  body,  but  a  few  of  the  commoner 
instances  may  be  mentioned  ;  several  are  illustrated  in  Plate  LIV.  The  skull 
frequently  presents  departures  from  the  normal,  in  ossification,  and  absence 
of  sinuses,  notably  the  frontal,  where  there  may  be  practically  no  air-cells, 
or  a  very  small  one  may  represent  the  frontal  sinuses.  The  sinuses  may  be 
abnormally  large,  and  extend  over  the  greater  part  of  the  frontal  bone  ;  one 
side  may  be  quite  normal  or  greatly  enlarged,  while  the  other  is  absent. 
Similarly  the  mastoid  air  sinuses  may  vary  to  a  hke  degree.  Abnormahties 
in  the  eruption  of  the  teeth  are  often  seen.  In  the  thorax  the  viscera  may 
be  transposed,  the  heart  being  on  the  right  instead  of  the  left  side,  the  aorta 
being  similarly  displaced.  The  stomach  is  occasionally  foimd  on  the  right 
side,  the  hver  being  then  on  the  left.  The  caecum  and  appendix  may  also 
be  found  on  the  opposite  side.  The  kidneys  may  be  represented  by  a  single 
horse-shoe-hke  structure,  or  a  kidney  is  found  on  the  one  side,  the  other 
being  absent.  It  is  important  in  connection  wth  kidney  operations  to 
bear  this  fact  in  mind. 

Many  deformities  of  the  bony  skeleton  are  met  mth.  One  arm  may 
be  represented  by  a  small  atrophied  structure  which  may  have  the  bones 
complete  or  may  show  remarkable  variations  from  the  normal.  The  fore- 
arm may  show  a  variety  of  departm-es.  Congenital  absence  of  a  bone  is 
not  uncommon.  The  wrist  and  hand  may  be  represented  by  a  small  fleshy 
mass  with  a  number  of  partially  ossified  bones  in  its  interior,  or  the  fingers 
may  be  webbed  or  joined  by  bone  to  each  other.  The  value  of  a  radiographic 
examination  in  these  cases  is  great,  for  by  its  means  it  is  often  possible  to 
determine  if  the  condition  can  be  remedied  by  operative  measures. 


PLATE  LIV. — Congenital  Deformities. 


a,  Meningocele  in  an  infant. 

h.  Congenital  deformity  of  foot  (Talipes  valgus). 

c,  Photograph  of  congenital  deformities  of  hands. 

d,  Radiograph  of  above. 


PART  II 
RADIATION  THERAPEUTICS 


INTRODUCTORY 

The  treatment  of  disease  by  radiation  naturally  divides  itself  into  : 

(1)  Treatment  by  X-rays  ; 

(2)  Treatment  by  Radinm. 

The  physics  of  radium  is  briefly  described  in  a  separate  section,  and  the 
production  of  X-rays  is  dealt  with  in  the  section  on  radiography.  A  separate 
section  of  the  book  is  devoted  to  the  consideration  of  practical  points 
in  the  use  of  X-rays  and  radium,  but  it  will  be  well  here  to  give  a  brief 
summary  of  the  general  effects  of  radiations  on  tissues. 

It  is  assumed  that  the  action  is  being  produced  by  the  radiations  from 
v/hichever  agent  is  being  used,  and  that  the  particular  effect  is  dependent 
upon  the  quality  of  the  radiation,  so  that  it  is  immaterial  from  which  source 
it  is  derived. 

The  work  of  Wickham  in  the  early  days  of  radium  therapy,  particularly 
in  the  treatment  of  superficial  lesions,  indicated  a  large  field  of  usefulness. 
Dominici,  working  almost  exclusively  with  the  Gamma  ray,  demonstrated 
that  far-reaching  effects  could  be  produced  by  filtering  the  radiations,  so 
as  to  exclude  all  but  the  Gamma  ray,  and  for  a  time  this  method  was  largely 
employed  in  the  treatment  of  mahgnant  disease.  It  has  been  found,  however, 
that  excellent  therapeutic  results  can  be  obtained  when  the  filtration  is  not 
nearly  so  great.  These  effects  must  be  due  to  Beta  and  Gamma  radiations. 
A  filter  of  -3  mm.  of  platinum  cuts  off  a  fairly  large  proportion  of  Beta  rays, 
but  allows  25  to  30  per  cent,  of  these  rays  to  pass  through,  and  exercise  an 
effect  upon  the  tissues.  There  is  therefore  a  tendency  now  to  cut  down  the 
filtration  in  order  that  the  therapeutic  action  of  both  rays  may  be  employed. 
This  is  particularly  so  when  radium  tubes  are  buried  in  the  substance  of 
tumours. 

The  biological  reaction  of  tissues  to  radiations  is  another  factor  which 
must  always  be  taken  into  consideration,  and  one  which  will  always  remain 
the  deciding  factor  in  the  choice  of  the  quality  and  quantity  of  rays  to  be 
employed.  That  is,  it  will  decide  the  question  of  filtration  and  time  of 
exposure.  It  is  this  factor  which  makes  radiation  therapy  so  difficult,  and 
largely  explains  the  diversity  of  results  obtained  by  many  workers.  It  is, 
for  instance,  a  common  experience  to  find  two  growths  of  apparently  similar 
nature  responding  differently  to,  as  far  as  can  be  judged,  precisely  similar 
conditions  of  ray  and  dosage. 

251 


252  KADIATION  THEEAPEUTICS 

The  employment  of  the  hardest  X-ray  it  is  possible  to  produce  at  the 
present  time  is  sometimes  followed  by  marked  results  in  the  treatment  of 
various  forms  of  carcinoma.  This  hard  X-ray  has  not  nearly  the  penetrating 
power  of  the  Gamma  ray  of  radium,  yet  in  some  cases  its  therapeutic  action 
is  quite  as  marked.  It  would  appear,  therefore,  that  a  wide  range  of  choice 
in  radiation  exists  in  the  field  of  practical  therapeutics.  It  is  sound  policy, 
in  the  present  state  of  our  knowledge,  to  combine  the  two  agents  whenever 
possible.  For  example,  a  carcinoma  of  the  breast  may  receive  thorough 
X-ray  treatment  as  a  preliminary  to  the  introduction  of  radium  tubes  into 
the  substance  of  the  growth.  The  advantage  of  using  X-rays  lies  in  the  fact 
that  treatment  may  be  quickly  administered  over  a  wide  area,  including  the 
growth  and  its  lymphatic  distribution.  The  resulting  reaction  may  lead  to 
a  limitation  of  the  growth,  and  in  some  instances  to  a  rapid  diminution  in  size. 
The  radium  tubes  may  be  introduced  into  the  substance  of  the  growth, 
and  continue  the  action  of  the  X-rays  at  a  deeper  level.  Subsequently  the 
X-rays  may  be  applied  at  regular  intervals  as  long  as  is  necessary.  Patients 
so  treated  undoubtedly  receive  great  benefit,  both  locally  and  constitution- 
ally. 

Action  of  Radiations  upon  Tissues 

The  action  of  radium  and  X-rays  upon  the  normal  tissues  and  on  morbid 
growths  is  not  as  simple  as  it  appears.  It  is  not  purely  a  caustic  action, 
though  caustic  effects  can  readily  be  produced  if  the  exposure  is  overdone, 
or  the  filtration  not  sufficient.  In  some  growths  this  action  is  deliberately 
made  use  of  in  order  to  produce  necrosis  of  the  mass,  in  the  hope  that  when 
the  slough  separates  normal  tissues  will  fill  in  the  resulting  ulcer.  On  the 
other  hand,  enlarged  glands  sometimes  disappear  with  hardly  any  skin  re- 
action. One  case  of  recurrent  sarcoma  of  the  neck  completely  cleared  up, 
with  merely  a  slight  reaction  of  the  skin  surface,  and  no  permanent  damage. 
A  case  of  epithelioma  of  the  tonsil,  involving  the  uvula  and  soft  palate, 
practically  disappeared,  leaving  a  healthy  soft  palate  and  uvula. 

In  addition  to  the  direct  evidence  of  a  local  action  of  radiations  upon 
the  cell  of  a  new  growth  and  its  surrounding  tissues,  there  is  reason  to  believe 
that  a  general  effect  is  produced  upon  the  whole  body.  This  is  indicated  by 
the  fact  that  patients  undergoing  treatment  by  X-rays  or  radium  occasion- 
ally improve  markedly  in  general  health.  They  gain  weight,  improve  in 
colour,  and  when  the  blood  is  examined  an  improvement  is  seen.  As  an 
illustration  of  this  beneficial  effect,  a  case  may  be  mentioned  where  treatment 
of  an  ulcerated  carcinoma  of  the  breast  was  followed  by  a  marked  improve- 
ment in  a  foul  vaginal  discharge  from  which  the  patient  suffered.  While 
growths  of  the  breast  are  being  treated  it  is  not  uncommon  to  find  glands  in 
the  axilla  and  other  parts  diminish  in  size.  This  is  also  observed  when  cases 
of  sarcoma,  lymphadenoma,  and  other  diseases  are  treated.  Whether  this 
is  the  result  of  a  general  stimulation  or  an  auto-vaccination  is  a  point  which 
has  yet  to  be  determined.     Experimental  evidence  is  forthcoming  which  goes 


ACTION  OF  RADIATIONS  UPON  TISSUES  253 

to  show  that  cancer  which  .has  been  treated  with  X-rays  or  radium  does 
not  grow  so  rapidly  when  injected  into  mice  as  growth  which  has  not  had 
such  treatment.  It  is  extremely  probable  that  radiations  of  X-rays,  radium, 
and  similar  agents,  do  exercise  a  general  as  well  as  a  local  effect  upon  living 
organisms.  The  general  effect  may  be  quite  as  useful  as  the  local,  and  if  it 
has  any  value  at  all,  it  would  be  extremely  useful  to  bear  in  mind,  because  one 
need  not  then  limit  the  area  of  exposure.  After  local  treatment  has  been 
pushed  to  its  limit  the  treatment  may  be  continued  in  other  parts  of  the 
body. 

The  following  observations  made  on  patients  undergoing  treatment  for 
malignant  disease  may  throw  some  light  on  the  problem  which  has  been 
engaging  our  attention  for  so  long.  In  the  course  of  treatment  of  cases  of 
leukaemia  the  fact  has  been  observed  that  marked  changes,  e.g.  a  diminution 
in  the  number  of  white  blood  corpuscles,  relative  and  absolute,  can  be  induced 
in  the  blood  by  radiations.  These  changes  are  obtained  when  the  splenic 
area  is  irradiated,  as  has  most  generally  been  the  method  of  treating  this 
disease.  The  same  changes  may  be  brought  about  when  other  parts  of  the 
body  are  subjected  to  treatment ;  thus  the  irradiation  of  the  ends  of  the  long 
bones  or  areas  of  the  abdomen  results  in  a  change  in  the  percentage  of  blood 
cells  and  a  reduction  in  the  size  of  the  spleen.  Observations  such  as  these 
lead  us  to  infer  that  the  beneficial  effects  of  X-rays  on  certain  cases  of  this 
disease  may  be  due  to  a  general  as  well  as  to  a  local  action.  Further,  it  has 
been  observed  during  the  local  treatment  of  carcinoma  of  the  breast,  that 
glands  at  a  distance  which  have  not  received  any  direct  treatment  have 
slowly  diminished  in  size.  It  has  also  been  noticed  during  the  treatment  of 
such  diseases  as  tuberculosis,  lymphadenoma,  and  sarcoma,  that,  while  the 
local  condition  has  improved  as  a  result  of  direct  treatment,  the  more  distant 
glands  have  also  diminished. 

The  writer  has  for  several  years  been  making  observations  on  blood 
changes  induced  in  patients  undergoing  treatment  by  radiations.  At  the 
commencement  of  these  observations  the  whole  attention  was  directed  to 
the  white  blood  cells,  which  were  observed  to  vary  considerably  at  different 
stages  of  the  disease  according  to  the  accompanying  infection,  and  also  as  a 
result  of  destructive  changes  occurring  in  the  tumour  and  surrounding  tissues. 

More  recently  attention  has  been  directed  to  the  behaviour  of  the  red 
blood  corpuscles  under  similar  conditions.  As  an  outcome  of  these  obser- 
vations it  can  be  stated  that  in  the  cases  where  the  percentage  of  red  blood 
cells  is  normal  or  over  and  the  haemoglobin  is  100  per  cent,  or  almost  so,  the 
response  to  treatment  is  more  rapid  and  lasting  than  when,  as  is  so  fre- 
quently the  case  in  advanced  stages  of  malignant  disease,  the  percentage  of 
red  cells  is  much  below  the  normal.  In  several  patients  whose  response  to 
X-ray  and  radium  treatment  has  been  rapid  and  marked,  the  percentage  of 
red  cells  has  been  well  over  the  normal.  One  case  recorded  well  over 
8,000,000,  and  the  haemoglobin  colour  iiidex  stood  at  100  per  cent.  Nearly 
every  case  which  showed  a  normal  or  plus  normal  condition  of  the  red  cells 
responded  well  to  X-ray  treatment. 


254  RADIATION  THERAPEUTICS 

In  view  of  the  excellent  work  done  on  secondary  radiations  of  metals 
by  Barkla,  Sadler,  and  others,  and  the  valuable  work  done  by  Hernemann 
Johnson  in  the  appHcation  of  metals  to  produce  the  secondary  radia- 
tions in  the  tissues  of  patients  treated  by  X-rays,  the  most  likely  explana- 
tion of  this  remarkable  response  in  these  cases  is  that  in  the  blood  stream 
there  exist  materials  which,  when  bombarded  by  the  radiations  of  X-rays  or 
radium,  throw  off  secondary  radiations  which  in  some  way  act  on  the  normal 
and  abnormal  tissue,  stimulating  the  former,  and  in  some  instances  damaging 
the  latter,  and  leading  to  a  diminution  in  the  size  of  the  tumour.  The  most 
likely  material  to  give  off  secondary  rays  is  the  hemoglobin  of  the  red  cells, 
which  is  a  compound  of  iron.  The  latter  metal  is  known  to  give  off  secondary 
radiations  when  exposed  to  X-rays.  It  is  interesting  to  note  that  iron 
stands  high  in  the  list  of  metals  which  give  off  radiations  when  struck  by 
X-rays.  These  radiations  are  independent  of  the  chemical  combination  of 
the  metals,  and  only  depend  on  the  quantity  of  the  metal  present.  It  must 
be  borne  in  mind  that  metals  require  a  particular  hardness  of  X-ray  to  enable 
them  to  emit  the  characteristic  secondary  radiations  peculiar  to  them.  This 
may  in  part  account  for  the  marked  degree  of  action  produced  in  cases  which 
have  a  high  percentage  of  haemoglobin.  It  also  throws  some  light  on  the 
cases  which  have  failed  to  respond  ;  possibly  the  particular  quality  of  X-ray 
employed  has  not  been  the  right  one,  or  the  exposure  has  not  been 
long  enough.  In  the  writer's  own  experience  the  best  results  have  been 
obtained  when  using  the  hardest  X-ray  possible,  combined  with  aluminium 
filters. 

The  hard  Beta  rays  and  the  Gamma  rays  from  radium  appear  to  exercise 
a  marked  influence  upon  some  cases  of  cancer.  The  duration  and  frequency 
of  the  exposures  also  play  an  important  part  in  the  results.  At  present 
experience  alone  can  show  us  how  and  when  to  repeat  the  radiations.  When 
the  necessary  secondary  radiation  values  of  the  constituents  of  a  malignant 
growth  and  of  the  blood  and  lymph  and  the  substances  they  contain  are 
known,  and  when  improvements  in  X-ray  tubes  and  control  apparatus 
enable  us  to  select  the  ray  which  will  cause  it  to  emit  its  secondary  radiation 
when  it  strikes  upon,  say,  the  iron  in  the  blood,  we  may  hope  to  produce  a 
reaction  in  and  around  the  growth  which  should  materially  help  us  in  treat- 
ment. Then  we  may  hope  for  marked  improvement  in  results.  It  is  prob- 
able that  we  have  here  also  an  explanation  of  the  changes  which  may  be 
induced  in  the  more  distant  parts  ;  the  blood  which  receives  local  treatment 
in  its  passage  through  the  growth  and  surrounding  tissues  is  acted  upon  by 
these  radiations,  and  the  effects  produced  on  the  cells  in  the  local  growth  are 
carried  on  to  the  other  parts  of  the  body,  and  exercise  a  stimulating  effect  on 
tissue  metabolism,  which  may  result  in  changes  in  these  parts.  The  sugges- 
tion is,  I  think,  one  well  worth  careful  consideration  and  investigation,  for 
here  we  possess  an  excellent  vehicle  by  means  of  which  we  can  obtain  second- 
ary radiations  from  direct  radiations  upon  particular  parts. 

The  obvious  inference  is  that  in  all  cases  of  malignant  disease  we  should 
endeavour  to  keep  the  red  blood  corpuscles  up  to  or  above  normal  and 


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PLATE  LV. — Changes  produced  in  Normal  Tissues  bt  Eadiations. 

A,  High-XDOwer  magnification.  Leucocytes  in  corneal  layer  of  epithelium,  squamous  cells  degener- 
ated, changes  in  nuclei. 

B,  High-i^ower  magnification.  Leucocyte  infiltration  of  an  ulcei-ated  surface,  obliterated  blood- 
vessel in  a  mass  of  degenerated  squamous  cells. 

C,  Section  showing  changes  in  bundles  of  muscle  fibres,  partial  destruction  of  two  small  bundles  (a), 
small  round-celled  invasion  (J),  increase  of  fibrous  tissue  between  the  muscle  fibres  (c),  and  atro^Dhy  of 
fibres  {d). 

D,  Muscle  fibres  in  longitudinal  section,  (a)  Small  round-cell  infiltration  ;  (&)  loss  of  striation  of 
muscle  fibres  ;  (c)  replacement  of  muscle  fibres  by  fibrous  tissue. 

E,  High-power  view,  showing  two  small  nerves  and  a  blood-vessel  surrounded  by  well-formed  fibrous 
tissue  ;  also  many  young  connective-tissue  cells.     There  are  a  few  fibro-blasts  in  the  large  nerve  trunk. 

F,  High-power  magiufication.  Squamous  epithelioma  with  patches  of  round-celled  inflammatory 
exudation  on  surface.  The  squamous  cells  next  to  this  are  large  and  irregular  and  a  few  leucocytes 
have  penetrated  between  the  cells. 


ACTION  OF  KADIATIONS  255 

increase  the  colour  value  by-giving  the  patient  iron  and  other  drugs  which 
are  known  to  exercise  a  tonic  effect  while  we  bombard  the  local  condition 
with  regular  doses  of  radiations.  Recently  some  cases  undergoing  radiation 
treatment  have  also  received  injections  of  salvarsan  ;  the  response  to  this 
combined  treatment  has  been  very  marked,  the  improvement  being  greater 
and  more  rapid  than  when  either  is  used  separately.  It  is  necessary, 
however,  to  watch  carefully  the  action  of  both  treatments,  and  especially 
that  of  the  radiations,  care  being  taken  not  to  press  the  dosage  too  rapidly, 
in  order  to  avoid  the  danger  of  too  sudden  and  far-reaching  changes  in 
the  blood  and  tissues.  The  radiation  employed  should  be  of  a  quality 
which  is  known  to  produce  the  secondary  effects  upon  the  iron  and  other 
substances  capable  of  producing  secondary  radiations  in  the  blood.  The 
treatment  of  malignant  growths  must  therefore  be  general  as  well  as  local. 
The  general  treatment  consists  of  a  suitable  diet,  plenty  of  fresh  air,  and 
iron  tonics — the  latter  in  excess  if  the  patient  is  tolerant. 

Rest  in  bed  during  treatment  should  in  some  cases  be  insisted  upon. 
The  local  treatment  should  consist  of  such  measures  as  will  induce  a  liberal 
flow  of  blood  to  the  part,  e.g.  : 

(a)  Brush  high-frequency  discharges,  which  are  very  useful  for  this 
purpose,  and  which  should  be  given  just  before  or  at  the  same  time  as  the 
X-ray  treatment. 

(6)  The  mercury  vapour  lamp,  which  also  induces  an  increased  super- 
ficial blood  flow. 

(c)  Diathermy.  This  form  of  high-frequency  current  is  said  to  increase 
the  sensibility  of  tissues  to  the  action  of  radiation.  Pre\aous  to  radiation 
treatment  the  parts  may  be  thoroughly  exposed  between  two  electrodes,  and 
radiation  treatment  then  applied.  Also,  the  X-ray  or  radium  exposures 
should  be  of  sufficient  duration  to  induce  and  keep  up  in  the  tissues  a 
moderate  degree  of  reaction. 

It  has  been  observed  in  treating  superficial  carcinoma  that  improve- 
ment hardly  ever  takes  place  until  this  degree  of  action  is  produced. 
In  severe  cases  the  reaction  may  require  to  be  marked.  Under  treat- 
ment of  this  kind  recurrent  nodules  and  primary  growths  of  considerable 
size  frequently  diminish  considerably,  and  larger  tumours  become  smaller, 
and  in  some  cases  are  rendered  operable.  Recurrent  nodules  and  small 
primary  growths  sometimes  entirely  disappear.  It  is  also  possible  that 
the  blood  serum  may  contain  substances  which  give  off  secondary  radia- 
tions which  alter  the  composition  of  the  serum.  A  great  deal  of  work  has 
been  done  in  this  direction.  Future  research  in  the  investigation  of 
physical  phenomena  should  be  directed  on  lines  which  are  likely  to  throw 
light  on  the  action  of  secondary  radiations  in  the  tissues  themselves.  By 
a  combined  attack  from  the  physical  and  clinical  aspects,  we  may  hope  in 
the  near  future  to  produce  a  marked  improvement  in  our  methods  of  treat- 
ment by  radiations,  which  should  result  in  material  benefit  to  patients 
suffering  from  malignant  disease. 


256  EADIATION  THERAPEUTICS 

Action  of  Radiations  on  Normal  Tissues  and 
Morbid  Growths 

That  radium  exercises  a  marked  influence  upon  tissues  and  tissue  meta- 
bolism is  an  admitted  fact,  but  the  nature  of  this  influence  is  still  imperfectly 
understood,  and  must  necessarily  remain  so  until  we  know  more  about  the 
biological  effects  of  radium. 

All  the  early  work  was  carried  out  under  conditions  of  partial  know- 
ledge. The  results  varied  as  a  consequence,  and  hence  conflicting  opinions 
were  promulgated,  in  many  cases  hastily,  on  the  value  of  radium  in  thera- 
peutics. 

It  may  be  stated  at  the  outset  that  all  living  tissues  are  affected  by  the 
various  rays  from  radium — Alpha,  Beta,  and  Gamma — to  an  unequal  extent, 
varying  with  the  particular  rays  which  predominate  in  the  exposure.  The 
predominance  of  any  particular  rays  depends  upon  the  quantity  of  radium 
used,  the  filtration,  the  distance  of  the  applicator  from  the  tissues  in  question, 
and  the  length  of  exposure. 

Action  on  Normal  Tissues. — Radium  acts  as  a  stimulant  to  normal 
tissues,  causing  congestion  of  the  areas  exposed  to  its  radiations,  which  con- 
gestion is  followed  by  an  increased  formation  of  fibrous  tissue.  If  the 
exposure  is  prolonged,  or  the  filtration  insufficient,  the  action  of  the  rays 
becomes  a  caustic  one,  and  an  acute  inflammatory  process  is  set  up,  which 
may  go  on  to  necrosis  and  sloughing  of  the  tissues  exposed. 

When  the  exposure  has  been  accurately  calculated,  the  inflammation 
slowly  subsides  after  a  given  time,  the  deeper  tissues  participating  in  the 
reaction  in  a  diminishing  ratio,  according  to  their  depth  from  the  surface. 
There  is  in  all  the  tissues  an  inflammatory  condition,  with  a  leucocyte  migra- 
tion and  an  invasion  of  small  round  cells.  When  this  subsides  fibrous  tissue 
formation  begins,  and  the  newly  formed  connective  tissue  with  its  capillary 
blood-vessels  may  surround  individual  cells  or  areas  of  cells,  and  by  subse- 
quent contraction  cut  off  the  blood-supply  of  these  areas,  which  then  undergo 
atrophic  changes.     Large  areas  of  debris  may  be  seen  in  the  section  examined. 

Action  on  the  Skin. — A  section  from  a  portion  of  skin  adjacent  to  a  new 
growth  which  was  treated  with  radium  shows  a  well-marked  leucocyte 
infiltration  in  the  cornual  layer  of  the  epidermis.  The  squamous  cells  are 
degenerated  and  have  lost  their  nuclei.  These  changes  are  noticed  when  the 
skin  has  been  subjected  to  prolonged  exposures,  the  atrophy  of  the  skin 
bearing  a  direct  relation  to  the  duration  of  the  exposure.  Skin  so  treated 
recovers  its  normal  condition  if  the  exposure  has  not  been  too  great.  The 
atrophic  changes  will  increase  as  the  dose  increases.  The  degenerative 
changes  occur  in  all  the  structures  forming  the  cuticle,  hair-bulbs  being 
damaged  or  destroyed. 

Action  on  Hair. — Hair  in  the  neighbourhood  of  an  area  treated  by  radia- 
tion will  lose  its  vitality  and  fall  out ;  a  permanent  alopecia  may  follow. 

Nerve  Tissue. — Nerve  fibres  may  become  influenced,  and  a  condition  of 


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PLATE  LVI. — Changes  observed  in  Tomouhs  which  have  been  treated  by  Radiations. 

A,  Low-power  view,  much  fibrous  tissue  with  many  young  connective-tissue  cells  and  a  large  number 
of  black  dots  representing  small  round  inflammatory  cells.  An  interpapillary  process  of  squamous  cells 
is  seen  on  the  upper  right  side.  Below  are  seen  numerous  large  cells  in  small  clusters  surrounded  by 
fibrous  tissue. 

B,  Collection  of  large  irregular  cells  embedded  in  hyaline  tissue  (fibrous),  many  of  the  cells  are 
of  the  typical  squamous  type.  There  are  many  small  round  inflammatory  cells  scattered  throiighout 
the  section  in  the  connective-tissue  stroma.  The  iipper  part  represents  the  ulcerated  surface  of  the 
tumour  and  is  composed  of  a  layer  of  fibrin  and  leucocytes. 

C,  Low-power  view  from  a  case  of  carcinoma  of  the  breast,  treated  with  X-rays  and  radium,  showing 
groups  of  cancer  cells  undergoing  degenerative  changes,  (a)  Fairly  active  group,  (&)  more  advanced 
degeneration,  (c)  hyaline  degeneration,  (d)  a  mass  of  fibrous  tissue. 

D,  High-power  view  of  several  groups  of  cancer  cells  showing  various  stages  of  degeneration. 

E,  High-power  view  of  portion  marked  c  in  C  ;  the  mass  is  filled  up  by  granular  debris  a  ;  h,  round- 
celled  infiltration. 

F,  A  section  from  a  case  of  carcinoma  treated  with  radium,  showing  excessive  fibrous-tissue  forma- 
tion ;  {c)  groups  of  cancer  cells  undergoing  degeneration. 


HLSTOLOGICAL  CHANGES  INDUCED  BY  RADIATIONS      257 

neuritis  or  perineuritis  be  set  up.  •  This  may  give  rise  to  a  considerable  degree 
of  pain. 

Action  on  Sweat  Glands. — These  are  readily  affected  by  radium  rays. 
The  preliminary  change  will  be  a  stage  of  engorgement  of  the  surrounding 
vessels  and  the  atrophy  may  be  marked.  Complete  destruction  of  the  gland 
will  be  the  result  of  over-exposm'e,  the  gland  becoming  involved  in  fibrous 
tissue.  This  action  on  sweat  glands  may  be  employed  in  therapeutics, 
wben  radium  may  be  used  instead  of  X-rays. 

Muscle  Fibres  undergo  a  degree  of  degeneration.  A  loss  of  stria tion  is 
seen,  and  a  form  of  hyaline  degeneration  follows.  The  muscle  bundles  are 
invaded  by  small  round  cells,  and  fibrosis  of  the  bundle  can  often  be  observed 
in  sections.  These  changes  are  seen  in  Figs.  C  and  D,  Plate  LV.  Fig.  C 
shows  a  transverse  section  of  bundles  of  muscle  fibres  which  were  removed 
from  a  patient  who  was  treated  Avith  radium.  The  section  shows  bundles 
of  muscle  surrounded  by  well-formed  fibrous  tissue  which  has  invaded  and 
partly  destroyed  two  of  the  smaller  bundles.  There  are  many  small  round 
inflammatory  cells  occupying  the  fibrous  tissue  and  in  parts  lying  between 
the  muscle  fibres.  The  general  appearance  is  suggestive  of  the  changes 
seen  in  cirrhosis  of  the  liver.  The  longitudinal  section  seen  in  Fig.  D 
shows  at  (a)  the  small  round  cell  infiltration,  at  (6)  muscle  fibre 
which  has  lost  its  striated  appearance,  and  at  (c)  the  dense  fibrous 
tissue. 

Blood  Vessels. — The  vessels  are  involved  in  the  general  inflammatory 
process.  There  is  a  proliferation  of  the  endothelium  of  the  small  capillaries, 
which  leads  to  occlusion  of  the  lumen,  and  consequent  arrest  of  the  circula- 
tion. The  large  vessels  show  a  proliferation  of  the  intima,  and  occasionally 
a  vessel  may  be  seen  with  the  lumen  occluded. 

Fig.  B,  Plate  LV.  illustrates  a  blood-vessel  in  a  section  which  shows 
leucocyte  infiltration  of  an  ulcerated  surface.  An  oval  patch  to  the  left  of 
the  section  represents  a  blood-vessel  which  has  become  occluded  and  is 
situated  in  a  mass  of  degenerated  squamous  cells.  Fig.  E  of  same  Plate  is  a 
high-power  view  of  a  section  showing  two  small  nerves  and  a  blood-vessel 
surrounded  by  well-formed  fibrous  tissue. 

Action  of  Radium  on  Vascular  Connective  Tissues. — The  dis- 
appearance of  inflammatory  conditions  and  tumours  on  which  radium  exer- 
cises an  action  eventually  depend  upon  two  phenomena,  which  are  as  follows  : 

(1)  The  destruction  by  radiations  of  the  anatomical  elements  modified 
by  inflammation  and  by  the  progress  of  the  tumour. 

(2)  The  absorption  of  degenerated  tissue  by  the  phagocytes,  and  its 
replacement  by  sclerotic  tissue. 

Wickham  and  Degrais  admit  that  these  phenomena  may  account  for 
changes  which  occur  in  some  afiections  treated  by  radium,  but  point  out  that 
this  is  not  the  only  result  of  the  process  when  radium  is  employed  on  in- 
flammatory conditions,  on  tumours  of  the  connective  tissue,  and  on 
epithelioid  tumours.  Instead  of  hastening  the  degeneration  of  connective 
tissue  cells  injured  by  inflammation  or  by  the  progress  of  the  tumour,  the 

17 


258  KADIATION  THERAPEUTICS 

radium  rays  revive  the  vitality  of  these  elements,  and  subject  them  to  an 
evolution  differing  from  that  which  the  pathogenic  influences  were  producing. 
The  special  action  of  the  Becquerel  ray  is  then  substituted  for  that  of  the 
pathogenic  process.  Their  effects  are  manifested  either  by  the  arrest  of  the 
inflammatory  process  or  by  the  resolution  of  the  tumour,  and  by  a  change  of 
structure  in  the  connective  tissue.  The  above  argument  is  open  to  criticism 
in  that  it  presupposes  a  selective  action  of  radiations  upon  pathogenic  pro- 
cesses and  connective  tissue  elements.  The  question  is  fully  dealt  with  later 
on,  but  it  may  be  said  here  that  the  difficulty  can  be  as  well  solved  by  the 
theory  that  as  radium  acts  on  all  tissues  in  varying  degree  according  to  the 
susceptibility  of  the  cell,  different  results  are  obtained  when  the  tissues  are 
more  resistant  than  when  they  are  less  so.  If  the  tumour  elements  were 
stimulated  as  well  as  the  connective  tissue  cells,  their  increase  in  growth 
would  lead  to  an  increase  in  the  size  of  the  tumour,  and  thus  the  pathogenic 
processes  referred  to  above  would  predominate  and  lead  to  a  further  destruc- 
tion of  the  anatomical  elements.  On  the  other  hand,  should  the  connective 
tissue  cells  receive  the  more  powerful  stimulation,  their  increase  would  be  the 
dominant  factor.  It  is  thus  possible  to  explain  all  the  changes  induced  in 
the  tissues  without  claiming  a  selective  action  for  radium.  Wickham 
and  Degrais,  however,  further  argue  :  "  This  change  consists  (a)  in  a 
metamorphosis  of  the  vascular  connective  tissue  into  angiomatous 
embryonic  tissue  ;  (6)  in  transformation  of  this  embryonic  tissue  into 
connective  fibrous  tissue  of  regular  texture.  In  such  a  case  the  healing 
of  inflammatory  conditions  or  of  tumours  is  the  function  of  a  special 
cellular  evolution  produced  by  the  Becquerel  rays.  The  healthy  connective 
tissue  itself  undergoes  this  evolution." 

Action  of  Radiations  upon  Tumour  Cells. — Occasionally  enlarged 
glands  are  reduced  in  size  with  hardly  any  skin  reaction  ;  nothing  more 
than  a  slight  erythema  may  be  produced  even  after  repeated  exposures  to 
the  same  area  of  skin,  yet  the  enlarged  glands  situated  at  a  much  deeper 
level  slowly  diminish  in  size. 

Malignant  indurated  ulcers  will  rapidly  break  down  and  heal  under  the 
action  of  radium. 

The  degree  of  action  induced  is  dependent  upon  the  method  of  applica- 
tion. The  various  degrees  of  tissue  change  depend  upon  the  filtration  em- 
ployed and  the  length  of  the  exposure.  Thus,  if  necrosis  of  the  growth  is 
necessary,  a  thin  filter  would  be  used  and  a  long  exposure  given.  Here  we 
are  making  use  of  the  Beta  ray  almost  entirely.  Should  it  be  necessary  to  act 
on  a  deeper  structure  and  at  the  same  time  protect  the  skin  from  such  action, 
a  thick  filter  of  platinum  or  lead  is  used.  Two  millimetres  of  platinum  or 
four  of  lead  are  sufiicient  to  cut  off  all  but  the  hardest  of  the  beta  rays,  while 
the  gamma  ray  is  unaltered.  The  filters  containing  the  radium  are  enclosed 
in  a  rubber  tube  to  prevent  the  secondary  radiation  induced  in  the  platinum 
by  the  radium  rays  from  damaging  the  superficial  structures.  If  the  exposure 
be  long,  further  protection  can  be  secured  by  using  an  inch  or  more  of  lint  or 
gamgee  tissue.     In  this  way  we  can  control  the  exposure  so  that  we  get 


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PLATE  LVII.— Changes  observeb  in  Tumours  which  have  been  treated  by  Radiations. 

A,  High-power  magnification  from  portion  of  Plate  LVI,  F,  marked  c. 

B,  High  maguification  of  groups  of  cancer  cells.     Cells  large  and  very  irregular  in  shape,  exudation 
is  marked  in  one  group  of  cells,  other  cells  show  division  of  nuclei. 

C,  High  magnification  of  groups  of  cancer  cells  embedded  in  fibrous  matrix,  leucocyte  infiltration. 

D,  High  magnification.     Another  field  from  same  section  showing  somewhat  more  advanced  changes 
of  a  like  nature. 

E,  High  magnification,  showing  a  mass  of  cellular  growth,  with  very  little  fibrous  tissue,  cells  large 
and  elongated,  nuclei  irregular  and  nucleoli  well  shown. 

F,  High  magnification  showing  fibrous  tissue  and  leucocytes  at  surface  with  hyaline  changes  ;  large 
irregular  cells  lie  in  loose  tissue,  they  are  pale  and  suggest  degenerative  changes. 


ACTION  OF  RADIATIONS  UPON  TUMOUR  CELLS  259 

nearly  the  pure  gamma-ray  effect.     This  enables  us  to  get  an  action  upon 
the  deep-seated  parts. 

It  has  been  claimed  that  radium  possesses  a  "  selective  action  "  on 
cancer  cells.  While  admitting  that  it  undoubtedly  appears  to  act  on  such 
cells,  the  word  "  selective  "  is  badly  used.  Radium  exercises  an  action  on 
all  living  cells  in  a  varying  degree  according  to  the  resistance  of  the  particular 
cell  in  question.  Thus,  young  actively  growing  cells  are  more  readily  in- 
fluenced than  mature  cells.  The  cells  of  a  new  growth  approximate  in  struc- 
ture and  power  of  resistance  to  the  actively  growing  cells  of  a  tissue.  In 
this  way  it  is  conceivable  that  the  cancer  cell  is  influenced  should  it  at 
the  time  of  exposure  be  comparatively  early  in  its  life-cycle.  Should  the 
cancer  cells  be  of  a  stronger  or  more  vigorous  type,  it  is  conceivable  that  the 
action  of  the  radium  may  be  stimulating,  and  instead  of  a  decrease  in  vigour 
of  a  particular  cell  we  may  find  an  increase  in  activity,  and  a  consequent 
increase  in  the  size  of  a  tumour.  It  is  a  fact  that  some  cases  of  cancer  increase 
in  size  at  a  quicker  rate  after  radium  has  been  applied.  Some  types  of  cancer 
are  more  amenable  to  radium  treatment  than  others. 

The  action  of  radiations  upon  tumour  cells  can  be  seen  from  a  number 
of  photomicrographs  from  sections  obtained  during  the  treatment  with 
radium  of  cases  of  growth.  These  sections  are  from  a  number  of  cases, 
but  some  are  from  the  same  case  at  different  periods  of  treatment.  They 
show  in  some  parts  marked  retrogressive  changes. 

Fig.  F,  Plate  LV. — A  section  of  tissue  adjacent  to  a  carcinoma  of  the 
arm  which  received  prolonged  radium  treatment.  There  is  a  marked  degree 
of  exudation  on  the  surface.  The  squamous  cells  adjoining  this  are  large 
and  irregular,  and  a  few  leucocytes  have  penetrated  between  the  cells. 

Fig.  A,  Plate  LVI. — A  low-power  view  of  another  section  from  the  same 
patient.  There  is  a  considerable  increase  of  fibrous  tissue  cells,  and  a  large 
number  of  black  specks  represent  small  round  inflammatory  cells.  An 
interpapillary  process  of  squamous  cells  is  seen  on  the  upper  left  side.  To 
the  right  below  are  seen  numerous  large  cells  in  small  clusters  separated 
by  fibrous  tissue.  These  cells  represent  all  the  new  growth  present  in  the 
field. 

Fig.  B,  Plate  LVI.  shows  a  small  collection  of  large  irregular- shaped  cells 
embedded  in  hyaline  tissue  (fibrous).  Many  of  the  cells  are  of  the  typical 
squanious  type,  and  are  separated  by  clear  intervals,  there  being  an  absence 
of  intercellular  substance.  The  upper  part  represents  the  ulcerated  surface 
of  the  tumour,  and  is  composed  of  a  layer  of  fibrin  and  leucocytes. 

Fig.  C,  Plate  LVI. — A  low-power  view  of  a  portion  of  tumour  removed 
from  an  atrophic  cancer  of  the  breast  after  repeated  X-ray  exposures,  followed 
by  one  exposure  to  radium,  applied  directly  over  the  portion  of  growth 
removed  for  examination.  It  shows  groups  of  cancer  cells  undergoing 
degenerative  changes,  (a)  A  group  of  cells  which  are  fairly  active.  The 
group  is  well  defined  at  its  edge,  and  is  surrounded  by  fibrous  tissue.  (6) 
A  group  of  cells  which  have  undergone  marked  degeneration.  There  are  a 
number  of  small  round  cells  in  the  group,     (c)  A  mass  of  cancer  tissue  which 


260  EADIATION  THEKAPEUTICS 

shows  more  marked  degenerative  changes,     (d)  Area  showing  excessive 
fibrous  tissue  formation. 

Fig.  E,  Plate  LVI.  — A  high-power  view  from  section  C  shows  a 
large  mass  of  cancer  cells  which  have  undergone  degeneration,  the  place 
of  the  cells  being  filled  by  granular  debris.  At  the  edges,  small  round-cell 
infiltration  is  seen. 

Fig.  D. — A  high-power  view  of  a  portion  of  tissue  from  the  same  case, 
showing  stages  of  degenerative  process. 

Fig.  F. — A  section  from  a  case  of  carcinoma  of  the  breast,  showing  (1) 
excessive  fibrous  tissue  formation  ;  (2)  malignant  cells  in  various  stages  of 
degeneration. 

Fig.  A,  Plate  LVII.  is  a  higher  magnification  of  a  portion  of  Fig.  F  in 
Plate  LVL,  a  group  of  cells  which  still  retain  their  activity.  Several 
of  the  cells  appear  to  have  degenerated,  and  there  is  evidence  of  nuclear 
changes. 

Fig.  B. — A  more  advanced  stage  of  change  in  cells  than  in  preceding 
figure.  The  cells  are  large  and  very  irregular  in  shape.  Vacuolation  is 
marked  in  one  group.     Other  cells  show  division  of  nuclei. 

Fig.  C. — A  group  of  cells  embedded  in  a  fibrous  matrix.  There  is 
marked  leucocyte  infiltration. 

Fig.  D  shows  a  similar  condition  and  a  more  advanced  stage  of  de- 
generation in  several  of  the  cells. 

Fig.  E. — A  mass  of  cellular  growth  with  practically  no  fibrous  tissue. 
The  cells  are  large  and  generally  elongated  in  shape.  The  space  between 
the  nuclei  is  irregular  and  the  nucleoh  are  well  marked.  This  is  a  condition 
of  the  cells  frequently  seen  in  these  cases.  Presumably  an  active  group  of 
cells  has  been  stimulated  to  increased  growth,  and  some  of  the  cells  have 
been  damaged  by  the  radiations. 

Fig.  F. — ^A  high-power  view  from  a  section  of  growth  showing  leucocytes 
at  surface  with  fibrous  tissue  formation.  Large  irregular  cells  he  in  a  loose 
cellular  tissue.     They  are  pale,  and  suggest  an  early  stage  of  degeneration. 

Fig.  A,  Plate  LVIII. — A  section  similar  to  the  last,  showing  leucocytes 
in  long  narrow  vessels  running  between  the  cells  of  the  growth. 

Fig.  B. — Another  section  near  the  surface  of  a  growth,  showing  much 
round-cell  infiltration  between  the  cells  of  the  growth. 

Fig.  C. — A  group  of  large  cancer  cells  in  the  midst  of  loose  fibrous 
tissue,  with  a  few  round  cells  interspersed. 

Fig.  D. — A  high -power  view  from  a  section  showing  the  surface 
of  the  growth.  A  group  of  large*  irregular  cells  in  alveoH  separated  by 
loose  connective  tissue.  These  cells  stain  well  and  have  large  nuclei, 
and  there  are  many  leucocytes  in  the  stroma.  The  tissue  is  denser  towards 
the  surface,  and  certain  concentric  bodies,  the  remains  of  cells  of  the  new 
growth,  are  present.  The  fibrous  tissue  of  the  walls  of  the  alveoh  of  growth 
collapse  as  the  growth  cells  are  destroyed.  The  blood-vessels  have  been 
obliterated.  The  surface  layers  of  the  tissue  are  denser  than  those  at  a 
deeper  level,  probably  the  results  of  the  action  of  the  radiations. 


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PLATE  LVIII. — -A  TO  D,  Changes  observed  in  Tumoues  which  have  been  treated  bt  Eadiations. 

A,  Another  view  from  same  section  of  tissue  as  F  in  preceding  plate.  Leucocytes  in  long  narrow 
vessels  running  between  the  cells  of  a  growth. 

B,  Another  section  near  the  surface  of  a  growth  showing  considerable  round-cell  infiltration  between 
the  cells. 

C,  Group  of  large  cells  in  the  midst  of  loose  fibrous  tissue  ;  there  are  very  few  round  cells  in  the 
fibrous  tissue. 

D,  High-power  view  of  surface  and  underlying  growth  ;  group  of  large  irregular  cells  in  alveoli 
separated  by  loose  connective  tissue  ;  nuclei  are  large  ;  tissue  denser  towards  the  surface  ;  and  con- 
nective bodies  are  seen  (remains  of  tumour  cells  ?)  blood-vessels  obliterated. 

E  AND  F,  Sections  from  a  Tumour  before  Treatment. 

E,  A  section  from  a  squamous-celled  carcinoma  before  treatment  with  radium,  showing  irregular  masses 
of  squamous  cells  divided  by  scanty  stroma  of  fibrous  tissue,  many  round  infiammatory  cells  ;  cell  nests. 

F,  Another  section  from  the  same  patient ;  tumour  cells  irregular  in  shape  with  a  tendency  to 
cornification  towards  the  centre. 


ACTION  OF  RADIATIONS  UPON  TUMOUR  CELLS  201 

Fig.  E,  Plate  LVIII. — A  -section  from  a  squamous- celled  carcinoma 
removed  from  a  tonsil  before  treatment  by  radium.  This  patient  completely 
recovered  after  thorough  treatment.  The  section  shows  irregular  masses 
of  squamous  cells  divided  by  scanty  stroma  of  fibrous  tissue,  in  which  there 
are  many  small  round  inflammatory  cells.  A  few  of  these  inflammatory 
cells  also  invade  the  groups  of  cancer  cells.  The  central  cells  of  several  of 
the  masses  are  large,  cornified,  and  form  typical  cell  nests. 

Fig.  F. — Another  section  from  the  same  case.  A  large  mass  of  growth 
on  right,  with  several  of?shoots  towards  the  centre.  The  cells  are  irre- 
gular in  shape  with  a  tendency  to  cornification  in  the  centre.  Smaller 
masses  of  cells  on  the  left  also  show  a  tendency  to  cornification  towards  the 
centre.  These  are  thickly  studded  \\nth  small  round  inflammatory  cells. 
A  few  of  these  round  cells  are  also  seen  among  the  squamous  cells  of  the 
growth. 

In  addition  to  the  action  upon  the  cancer  cell  itself,  radium  acts  upon 
all  the  tissues  composing  the  growth  and  surroimding  structures  unequally. 
There  is  a  general  stimulation  of  the  healthy  tissues  as  a  result  of  radium 
treatment  so  long  as  the  exposure  is  not  excessive.  If  it  should  be  excessive 
the  action  is  apt  to  produce  a  caustic  and  ulcerative  effect,  which  leads  to 
local  death  of  the  tumour  and  a  portion  of  the  tissues  around  it.  This  may 
sometimes  be  desirable. 

When  the  effect  upon  the  healthy  tissues  is  confined  to  stimulation, 
we  expect  to  find  an  increase  of  fibrous  tissue  formation,  which  shuts  off  the 
cancer  tissue  from  its  blood-supply  and  causes  the  atrophy  of  such  cells. 
The  reparative  power  of  the  normal  tissues  is  strengthened,  enabhng  them 
to  cope  with  the  invading  cells  and  lead  to  their  destruction.  These  changes 
can  be  seen  in  sections  removed  from  cases  undergoing  treatment. 

The  changes  induced  in  malignant  growths  by  the  action  of  radium  and 
similar  agents  are,  so  far  as  we  can  see,  indistinguishable  from  the  degenera- 
tive changes  seen  in  cases  of  growth  which  have  received  no  treatment ;  but 
this  important  point  must  be  insisted  upon,  that  the  percentage  of  cases 
in  which  we  see  these  changes  is  much  larger  in  the  group  of  cases  treated  by 
radiations  than  in  the  group  which  has  received  no  treatment. 

It  must  be  admitted  that  occasionally  we  see  a  case  of  untreated  can- 
cer diminish  in  size  and,  in  a  very  small  percentage,  ultimately  disappear. 
During  the  treatment  of  cancer  by  radiations  it  is  by  no  means  uncommon 
in  a  fairly  large  percentage  of  our  cases  to  see  a  marked  diminution  in  size 
produced.  In  a  smaller  percentage  we  do  see  the  growth  disappear — at 
all  events  for  a  time. 

The  local  disappearance  of  a  growth  is  not  a  cure.  The  disease  may 
have,  and  in  the  majority  of  cases  undoubtedly  has,  extended  to  other  parts 
of  the  body.  Consequently  no  case  can  be  said  to  have  been  cured  until  we 
have  given  the  deeper  ramifications  of  the  growth  sufficient  time  to  develop 
and  manifest  their  presence.  It  is,  therefore,  important  that  before  we  treat 
the  local  condition  a  search  be  made  for  secondary  deposits.  From  the 
point  of  view  of  prognosis,  this  is  a  most  important  matter. 


262  RADIATION  THERAPEUTICS 

Factors  influencing'  the  Result  of  Treatment. — In  routine  treatment 
by  radium,  the  following  factors  should  always  be  kept  in  mind,  as  a  full 
consideration  of  all  in  each  case  will  help  us  to  foretell  the  degree  of  action 
and  the  result  likely  to  follow  from  treatment : 

(a)  Type  of  growth  and  condition  of  patient. 
(6)  Situation  of  the  tumour,  size,  etc. 

(c)  The  quantity  of  radium  used. 

(d)  The  filtration  employed. 

(e)  The  duration  of  the  exposure. 

An  improvement  in  the  results  at  present  obtainable  by  radium  in  the 
treatment  of  malignant  disease  may  be  obtained  : 

(a)  Larger  quantities  of  radium  may  be  used.  Up  to  the  present  the 
largest  quantity  used  has  been  about  1  gram  of  pure  radium  salt.  Far- 
reaching  effects  may  be  produced  by  such  treatment,  especially  if  the  filtra- 
tion is  great  and  the  exposure  prolonged  ;  yet,  even  with  such  a  dose,  the 
result  in  several  cases  has  been  temporary  benefit  only.  The  type  of  case 
so  treated  has  been  a  deep-seated  growth,  which  could  only  be  acted  on  by 
the  very  penetrating  rays.  For  surface  lesions  the  increased  dosage  may 
have  a  speedier  effect,  which  should  help  to  prevent  the  spread  of  the  growth 
to  deeper  structures  if  it  can  be  efficiently  checked. 

(6)  A  more  thorough  knowledge  of  the  physical  properties  of  radium 
may  enable  us  to  select  for  particular  cases  the  quality  of  radiations  likely 
to  influence  the  cell  metabolism. 

(c)  It  must  be  admitted  that  the  technique  has  hitherto  been  more  or 
less  faulty.  A  fuller  knowledge  of  the  influence  of  the  various  thicknesses  of 
filters  may  help  us  to  get  speedier  results.  It  may  be  that  the  use  of  the 
Beta  rays  in  some  cases  would  lead  to  better  results.  Similarly  the  Alpha 
rays,  which  up  to  the  present  have  been  little  used,  may  in  the  future  be 
found  to  exercise  an  inhibitory  effect  upon  morbid  processes  when  they  are 
brought  into  contact  with  the  cells  of  a  growth.  The  difficulty  has  been 
to  apply  them  at  all.  The  radio-active  waters  at  present  in  use  do  not 
appear  to  have  any  influence  on  cancer  cells. 

It  may  be  possible  to  deposit  the  active  principles  of  the  radium  emana- 
tions in  such  a  way  that  we  can  utilise  them  either  by  direct  application  or 
by  ionisation  with  the  aid  of  a  galvanic  current,  or  a  combination  of  radia- 
tions may  be  helpful.  In  several  cases  radium  and  X-rays  together  appear 
to  have  hastened  reparative  processes.  It  is  possible  that  some  of  the  effects 
noticed  may  be  due  to  secondary  radiations,  produced  in  the  structures 
composing  the  growth,  which  exercise  a  physiological  action.  Some  such 
general  action  appears  to  take  place,  because  it  is  quite  a  common  occurrence 
for  patients  so  treated  to  improve  in  general  health. 

The  employment  of  radiations  in  any  form  leads  to  a  constitutional 
disturbance  which  we  designate  as  reaction.  This  varies  in  time  of  onset 
according  to  the  dosage.  After  a  time  a  period  of  depression  sets  in,  most 
probably  due  to  a  change  set  up  in  the  growth  which  leads  to  the  liberation 


DANGERS  OF  X-RAYS  AND  RADIUM  263 

of  toxins  into  the  circulation,  -  If  they  are  excessive,  the  condition  of  the 
patient  may  be  rendered  serious.  This  form  of  toxaemia  is  met  with  when 
large  rectal  growths  are  treated.  It  is  possible  to  make  the  condition  of  the 
patient  much  worse  if  care  is  not  taken  to  regulate  the  dose. 

Up  to  the  present  the  treatment  of  malignant  disease  by  radium  and 
other  radio-active  bodies  has  been  purely  local.  Consequently  it  cannot  be 
regarded  as  a  specific  method  of  treatment.  The  conditions  under  which 
it  may  become  so  are  being  investigated.  The  endeavour  must  be  to  procure 
a  substance,  radio-active  or  not,  which,  when  introduced  into  the  general 
circulation,  will  influence  morbid  processes  in  the  tissues.  It  may  be  possible 
to  use  a  substance,  which  when  treated  locally  by  radium,  X-rays,  or  other 
agents  capable  of  exciting  the  secondary  radiations  of  such  substances,  will 
benefit  the  tissues. 

The  best  we  have  yet  been  able  to  do  has  been  by  local  stimulation  to 
produce  secondary  radiations  from  the  tissues,  blood,  and  lymph  in  the 
deposits  of  cancer.  When  the  secondary  radiation  value  of  these  tissues  is 
better  known,  and  when  we  know  which  particular  radiation  acting  upon 
them  will  give  us  their  maximum  value,  then  we  may  hope  to  improve  our 
results. 

Dangers  attendant  on  the  use  of  X-Rays  and  Radium 

In  the  routine  treatment  of  disease  by  radiations,  even  when  the  greatest 
care  is  exercised  as  to  dosage  and  frequency  of  application,  it  is  inevitable 
that  cases  should  occur  in  which  in  spite  of  all  precautions  serious  damage 
is  done.  It  is  therefore  necessary  to  consider  briefly  the  ill-effects  which 
may  accompany  the  use  of  radiations.     These  are  : 

(1)  Acute  Dermatitis. 

(2)  Chronic  Dermatitis. 

(3)  Late  Manifestations,  appearing  a  long  time  after  cessation  of 
treatment. 

Acute  Dermatitis. — A  properly  judged  dose  of  X-rays  or  radium, 
when  applied  to  the  skin  surface  after  a  given  time,  produces  a  definite 
erythema,  which  causes  a  slight  reddening  of  the  surface.  This  lasts  a  few 
days  and  then  slowly  subsides.  When  such  a  dose  has  been  applied  to  a 
surface  covered  with  hair,  complete  epilation  follows  ;  the  follicles,  however, 
are  not  destroyed,  and  the  hair  reappears  later.  Should  the  reaction  be  ex- 
cessive, and  the  skin  surface  ulcerate,  more  or  less  permanent  alopecia  may 
result.  All  degrees  of  reaction,  from  a  slight  erythema  to  deep  ulceration, 
may  follow  a  single  exposure  to  either  X-rays  or  radium.  Acute  dermatitis 
is  frequently  met  with  in  the  treatment  of  malignant  disease  where  the  dosage 
has  been  energetically  pushed.  This  may  lead  to  large  superficial  ulcers, 
which  are  extremely  painful  and  very  difficult  to  heal.  Deep  sloughs  may 
form  and  separate,  leaving  large  ulcers. 

Chronic  Dermatitis. — The  acute  dermatitis  may  only  partially  subside, 
and  give  rise  to  a  subacute  or  chronic  condition  which  may  be  very  intractable, 


264  RADIATION  THERAPEUTICS 

persist  for  years,  and  finally  take  on  a  malignant  character.  This  form  is 
commonly  met  with  among  X-ray  operators  who  were  injured  in  the  early 
days  of  X-ray  work.  The  degree  of  damage  caused  to  the  tissues  may  be 
reckoned  by  the  period  of  incubation,  i.e.  the  time  between  the  exposure  and 
the  first  appearance  of  redness.  Irritation  is  more  marked  in  the  subacute 
and  chronic  forms  than  in  the  acute,  desquamation  being  more  marked  in 
the  acute.  X-ray  warts  are  a  late  manifestation  of  chronic  dermatitis, 
and  may  become  malignant. 

Late  Manifestations. — A  frequent  sequel  to  X-ray  and  radium 
treatment  is  the  occurrence  of  telangiectasis  many  months  after  the  cessation 
of  treatment.  The  length  of  time  which  may  elapse  between  the  cessation 
of  treatment  and  the  appearance  of  telangiectasis  is  much  greater  than  was 
formerly  supposed.  A  case  was  seen  recently  occurring  in  the  hands 
where  the  treatment  with  filtered  rays  had  been  carried  out  for  hyper- 
hidrosis.  Three  years  afterwards  the  palms  of  both  hands  were  covered  with 
patches  of  telangiectasis,  with,  in  addition,  a  certain  degree  of  pain  and 
irritation.  They  are  somewhat  unsightly  and  difficult  to  treat.  They  are 
more  likely  to  appear  when  mifiltered  rays  have  been  used.  Late  ulceration 
is  a  condition  which  has  been  described  by  several  writers  as  coming  on  many 
months,  or  even  a  year  or  two,  after  the  cessation  of  treatment.  It  is 
extremely  painful  and  intractable. 

Cases  treated  by  radiations  sometimes  show  evidence  of  neuritis.  This 
is  especially  liable  to  occur  in  the  treatment  of  cases  of  carcinoma  of  the  breast 
in  the  axillary  and  supraclavicular  regions,  owing  to  the  presence  of  large 
nerve  trunks  in  these  parts.  The  condition  is  often  very  painful,  but  gener- 
ally subsides  on  the  cessation  of  treatment.  When  very  painful,  relief  may 
be  obtained  by  the  use  of  the  galvanic  current  along  the  course  of  the  nerves. 
It  is  quite  possible  that,  where  deep-seated  organs  are  subjected  to  heavy 
dosage  in  the  intensive  treatment  by  X-rays,  organs  other  than  those  treated 
may  be  seriously  damaged.  A  considerable  time  must  elapse  before  we  can 
definitely  state  that  this  intensive  treatment  cannot  produce  effects  other 
than  those  aimed  at.  In  estimating  the  value  of  X-ray  treatment  in  myoma 
uteri,  the  above  possibility  must  be  borne  in  mind  before  we  can  admit  the 
successes  claimed  for  it  by  enthusiastic  advocates.  The  occurrence  of  late 
manifestations  on  the  skin  surface  after  prolonged  radiation  treatment  leads 
to  the  inference  that  deep-seated  changes  may  also  occur. 


A.  X-RAY  THERAPEUTICS 
Special  Points  in  Instrumentation 

Before  we  proceed  to  a  detailed  description  of  the  methods  of  treatment, 
apparatus,  dosage,  etc.,  there  are  several  factors  of  a  preliminary  nature 
which  must  be  discussed  at  some  length. 

The  general  principle  of  radio-therapeutics  is  as  yet  imperfectly  mider- 
stood.  The  action  of  X-rays  on  tissues  has  been  too  well  demonstrated  by 
the  unfortunate  effects  upon  many  of  the  early  workers.  An  agent  so 
capable  of  harmful  effect  must  necessarily  be  treated  with  a  considerable 
amount  of  respect  when  used  for  therapeutic  purposes. 

There  is  still  a  large  field  for  experimental  work  in  the  perfection  of 
apparatus,  the  standardisation  of  tubes  and  dosage  and  therapeutic  tech- 
nique. The  early  work  was  chiefly  confined  to  superficial  areas  of  the  body, 
and  it  was  the  observation  of  the  effect  upon  these  structures  and  diseases 
which  encouraged  workers  to  develop  and  elaborate  the  technique  of  the 
present  day.  Great  improvements  in  superficial  lesions  of  the  skin  through 
the  use  of  X-rays  led  to  the  employment  of  the  rays  in  the  treatment  of  deep- 
seated  diseases.  The  employment  of  filters  for  the  protection  of  the  super- 
ficial structures  from  the  action  of  the  soft  X-rays  enabled  the  experimenters 
to  evolve  a  technique  for  the  treatment  of  such  diseases  as  uterine  myomata 
and  cancer.  The  action  of  the  Gamma-ray  of  radium  upon  cancer  led  X-ray 
therapeutists  to  use  harder  tubes  and  increased  filtration  with  larger 
exposures.  More  accurate  measures  for  estimation  of  dosage  increased  the 
value  of  these  experiments,  while  the  improvement  in  apparatus,  particularly 
in  the  focus  tube,  ensured  the  administration  of  larger  doses  of  more 
penetrating  rays. 

Methods  of  Protection 

The  first  care  of  all  workers  should  be  to  ensure  the  complete  protection 
of  the  operator  and  attendants  in  an  X-ray  department,  and  there  can  be  no 
doubt  that  at  present  too  little  attention  is  paid  in  most  electrical  cliniques 
in  this  country  to  the  important  question  of  X-ray  protection. 

It  is  not  sufficient  to  enclose  the  X-ray  tube  in  a  lead-glass  shield,  closed 
only  on  one-half  of  its  diameter.  X-rays  escape  from  behind  the  tube, 
and  in  addition  there  are  the  rays  of  which  we  yet  know  little,  which  may 
have  an  injurious  effect  upon  the  workers  ;  also  high-tension  currents  are 
allowed  to  escape  through  the  room,  and  there  is  at  present  no  accurate 
knowledge  of  the  ill-effects  which  may  be  produced  by  frequent  and  pro- 
longed exposure  to  their  influence. 

265 


266 


KADIATION  THERAPEUTICS 


Complete  protection  can  be  obtained  by  enclosing  tbe  X-ray  tube, 
together  with  the  patient  and  the  auxiliary  apparatus,  within  a  lead-lined 
cubicle.  Lead  of  the  thickness  of  1  mm.  or  more  should  be  let  in  between 
the  layers  of  wood,  the  wood  covering  serving  to  absorb  secondary  radiations 

given  off  from  the  lead 
when  struck  by  X  -  rays. 
The  upper  portion  of  the 
cubicle  may  have  lead-glass 
windows  in  order  that  the 
operator  may  see  the  work 
being  done  inside.  These 
cubicles  should  have  an 
efficient  system  of  ventila- 
tion. Indeed,  too  great 
stress  cannot  be  laid  upon 
this  point.  All  X-ray  rooms, 
cubicles,  and  dark  rooms 
should  be  efficiently  venti- 
lated, and  in  hospitals  they 
should  also  be  easy  to 
disinfect.  The  control 
apparatus  should  be  on  the 
outside  of  the  cubicle.  In 
some  institutions  an  arrange- 
ment is  added  whereby  the 
current  can  be  automatically 
cut  off  when  the  door  of  the 
cubicle  is  opened. 

When  such  elaborate 
precautions  are  not  avail- 
able, it  should  be  the  duty 
of  those  responsible  for  the  X-ray  department  to  see  that  efficient  pro- 
tection is  provided. 

The  X-ray  tube  should  be  completely  enclosed  in  a  lead-lined  box,  or 
a  lead-glass  shield  of  sufficient  size  should  be  provided,  so  that  no  stray 
X-rays  are  allowed  to  fall  outside  the  area  it  is  desired  to  treat.  Gloves 
should  be  used  whenever  the  operator  comes  within  the  range  of  the  rays. 
A  large  lead-lined  screen  should  be  placed  between  the  active  tube  and  the 
worker.  This  should  have  a  lead-glass  window  for  purposes  of  observa- 
tion on  patient  and  tube.  The  control  apparatus  should  be  kept  at  a 
considerable  distance  from  the  tube  stand  so  that  the  operator  need  not 
come  near  the  active  ray. 

Protection  of  the  patient  must  be  carefully  attended  to,  especially  when 
administering  the  heavy  doses  of  more  recent  days.  Thick  lead -rubber 
shields  should  cover  the  parts  of  the  body  in  close  proximity  to  the  tube  box. 
A  window  is  cut  in  the  middle  of  the  lead  rubber  to  allow  of  the  rays  passing 


Fig.  185. — X-ray  treatment  cubicle.      {Archives  of  Rontgen 
Ray. )     Control  apparatus  arranged  outside  the  cubicle. 


AERANGEMENT  OF  APPARATUS  267 

to  tlie  part  under  treatment.  ..^  The  efficiency  of  the  protective  measures 
employed  may  be  tested  by  means  of  an  electroscope.  This,  when  placed 
in  the  vicinity  of  an  active  X-ray  tube,  quickly  becomes  discharged,  thus 
enabling  the  ionisation  effect  to  be  estimated.  All  protective  devices 
should  be  tested  in  this  manner  before  it  is  assumed  that  they  are  efficient. 

Arrangement  of  Apparatus 

In  the  early  days  it  was  sufficient  to  have  a  coil,  control  apparatus,  and 
a  tube,  the  dose  being  calculated  in  minutes,  in  many  instances  quite  irre- 
spective of  the  condition  of  the  tube.  Even  with  this  crude  technique  results 
were  obtained  which  served  to  call  attention  to  the  great  potentiality  behind 
the  new  remedy.  Increasing  complexity  of  apparatus  accompanied  each 
succeeding  development,  so  that  the  equipment  for  an  X-ray  therapeutic 
department  has  now  become  exceedingly  complicated. 

The  control  of  the  X-ray  tube  is  a  matter  of  ease  when  precautions  are 
taken  and  sufficient  auxiliary  apparatus  is  provided. 

A  Switchboard  on  the  wall  or  on  a  trolley  table  is  essential.  It  should 
have  an  ammeter  to  measure  the  primary  current,  a  resistance  to  control 
the  current  in  the  primary,  a  resistance  for  the  control  of  the  break,  and 
switches  to  control  these  parts. 

Valve  Tubes  should  be  provided  wherever  there  is  a  suspicion  of  reverse 
current.  It  is  a  good  plan  to  have  valve  tubes  and  oscilloscope  tubes 
arranged  so  that  they  may  be  cut  off  from  the  current  when  not  required. 
They  may  be  introduced  occasionally  to  see  if  there  is  any  reverse  current 
present.      This  is  all  that   is  necessary   when  ..-^^^^s^fci^ 

small  currents  are  used.  >^^^^^^^Sv^^ 

A  milliamperemeter  measuring  approxi-      .^fl^^^^^^B^V^k 
mately  the  quantity  of  current  passing  through    /jy^^^^^^^^^^^^^B 
the  tube,  is  an  essential  if  reliable  work  is  to   fffll^^^^^lHH  ■■ 
be  expected.     It  should  be  of   the  very  best  \l^v/^^H^^!^f  Mm 
D'Arsonval  moving'-coil  dead-beat  precision    ^^^2  'i^l}^\y'S'l^ ^m 
type,    which  is  provided   with  two  readings,        ^^^^tU^^^^J^r 
viz.,  0-5  and  0-50  m.a.     On  the  lower  reading  ^-^^rfl^^^ 

each  one-fifth  part  of  a  milliampere  is  clearly  «l^^| 

registered,   while  on  the  higher  reading   each  W^^m 

division  of  the  scale  represents  two  milliamperes.  JlflH 

In  all  ordinary  work  only  one  or  two  milh-  m 

amperes  are  utilised  through  the  focus  tube,  so 

that  the  lower  reading  serves  admirably,  while      ^'''•^^*^7s-™en"r''"'*'^ 
for  very  heavy  discharges  the  higher  reading  is 

called  into  use.  The  miUiamperemeter  enables  the  operator  to  estimate 
approximately  the  hardness  of  the  tube,  as  the  variations  may  be  detected 
by  the  fluctuations  of  the  recording  needle.  As  the  tube  hardens  the 
amount  of  current  passing  through  diminishes  and  mce  versa.  In  treatment 
it  may  be  used  as  a  guide  to  the  length  of  the  exposure  if  care  has  been 


268 


EADIATION  THERAPEUTICS 


taken  to  note  the  condition  of  the  tube  as  to  hardness  and  quantity  of 

current  when  a  particular  dose  is  being  given. 

The  Qualimeter  of  Bauer  is  a  useful  adjunct  to  a  treatment  outfit, 
enabling  one  at  a  glance  to  estimate  approxi- 
mately the  degree  of  hardness  of  the  tube. 

Bauer's  Qualimeter. — The  instrument  is  sus- 
pended from  the  wall  of  the  protective  house 
or  protective  screen,  and  indicates  the  hard- 
ness of  the  focus  tube  on  a  scale.  It  does  not 
depend;  as  in  other  scales,  on  the  comparison  of 
different  tints. 

This  instrument  is  connected  by  a  wire  to 
the  negative  terminal  of  the  coil  or  the  cathode 
of  the  tube.  It  is  a  static  electrometer  and 
condenser  which  indicates  automatically  the 
potential  of  the  cathode,  and  hence  the  quality 
of  the  X-rays.  The  apparatus  consists  of  two 
wings,  which  swing  between  two  fixed  plates. 
Both  wings  and  plates  are  equally  charged  so 
that  a  repulsion  takes  place  between  them.  The 
intensity  of  this  repulsion  is  in  exact  proportion 
to  the  electrical  tension  in  the  secondary  circuit, 
and  is  indicated  by  the  deviation  of  a  pointer 
over  a  suitably  divided  scale. 

As  is  well  known,  the  penetration  of  the 
X-rays  is  a  function  of  the  electrical  potential  in 
the  secondary  circuit,  so  that  a  simple  measure- 
ment of  this  potential  between  the  anode  and 
cathode  will  give  us  an  indication  of  the  hardness  of  the  tube.     The  scale  is 
gauged  according  to  the  absorption  of  the  X-rays  by  sheets  of  lead  of  different 
thickness,  increasing  regularly  from  yV  of  a  millimetre  to  1  millimetre. 

No.  1  on  the  scale  denotes  X-rays  of  such  a  hardness  as  to  be  totally  absorbed 
by  yV  milhmetre  of  lead.  When  the  index  is  at  No.  10  we  know  that  the  tube 
is  giving  out  rays  which  will  penetrate  0*9  millimetres  of  lead,  but  will  be  totally 
absorbed  by  1  millimetre  of  lead. 

As  already  explained,  the  instrument  is  unipolar,  being  joined  up  by  a  single 
wire  to  some  point  in  electrical  connection  with  the  cathode.  The  instrument  is 
contained  in  an  ebonite  case,  which  swings  freely  from  a  bracket  on  the  wall  or  a 
stand,  so  as  to  be  always  in  a  vertical  position.  It  should  be  within  view  of 
the  operator,  to  enable  him  to  estimate  the  hardness  of  his  tube  throughout  the 
whole  of  the  exposure,  without  danger  to  himself. 


Pig.  187. — Bauer  qualimeter. 
(Favre.) 


Comparative  Scale  of  the  usual  Instruments  foe  Measuring 
THE  Hardness  of  Tubes 

soft 


medium 


hard 


Bauer  .... 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

Wehnelt       . 

1-5 

3 

4-5 

6 

7-5 

9 

10-5 

12 

13-5 

15 

Walter  .... 

1 

1-2 

2-3 

3-4 

4-5 

5-6 

6-7 

7-8 

Benoist 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

THE  THERAPEUTIC  COIL 


269 


It  is  well  to  have  all  these  instruments — valve  tubes,  miUiamperemeter, 
qualimeter,  and  oscilloscope  tube — in  the  circuit,  especially  when  a  great 
deal  of  work  has  to  be  done,  as  they  facilitate  speed  in  working,  and  enable 
the  operator  to  see  that  the  conditions  under  which  his  work  is  being  carried 
out  are  correct. 

The  Therapeutic  Coil  should  be  at  least  twelve  inches  spark-gap,  and 
where  more  than  one  is  possible  a  16-inch  coil  should  be  installed.  Any 
modern  coil  is  adequate,  but  the  type  likely  to  give  the  best  results  is  one  of 


spark-gap 


MiUianippremetftr 


Coil  enclosed 


Interrupter 


Rhythmeur 


Fig.  188. — Therapeutic  oiitflt  suitable  for  deep  therapy.      (Schall. ) 
The  interrupter   is    arranged    for  the  passage  of  heavy  currents.      At  the  top  of  the  motor 
a  small  fan   is  arranged  to  drive   a   current  of  air  through   the  primary  of  the  coil  for  cooling 
purposes.     A  rhythmeur  is  arranged  below  the  mercury  interrupter. 

the  so-called  intensive  coils  ;  that  is,  one  giving  a  high  secondary  output 
with  a  moderate  primary  current.  When  possible,  the  coil  should  be  mounted 
well  away  from  the  control  apparatus,  and  the  terminals,  high-tension  cables, 
etc.,  should  be  separated  as  widely  as  possible  to  prevent  a  leak  to  earth  or 
sparking  between  the  terminals.  With  the  larger  coil  it  should  be  possible 
to  pass  heavy  discharges  through  the  hardest  X-ray  tube.  The  Coolidge 
tube  requires,  when  very  hard  rays  are  used,  a  heavy  discharge  from  the 
secondary.  This  may  be  obtained  from  the  larger  coils  now  in  use.  When 
these  very  hard  tubes  are  used  the  high  tension  transformer,  such  as  the 


270 


KADIATION  THEKAPEUTICS 


Snook  machine,  will  be  found  extremely  useful.     The  control  of  the  tubes 
when  using  the  unidirectional  current  obtained  from  this  type  of  transformer 

is  a  matter  of  comparative  ease. 
The  Interrupter. — A  con- 
denser is  necessary  when  the 
interrupter  is  of  the  mercury- jet 
type,  as  is  also  a  condenser 
battery  when  the  apparatus  is 
used  for  many  hours  daily.  The 
battery  should  be  arranged  so 
that  it  is  convenient  to  quickly 
change  from  one  set  of  con- 
densers to  another. 

The  mercury  jet  interrupter 
has  already  been  described,  see 
page  17,  and  little  more  need  be 
added  here.  The  best  di-electric 
to  employ  is  coal  gas  ;  a  supply 
pipe  with  a  tap  being  run  from 
the  main  to  the  apparatus, 
to  which  a  length  of  rubber 
tubing  is  attached,  and  this  is 
carried  to  the  inlet  tap  on  the 
interrupter.  Before  turning  on 
the  main  switch  to  the  appar- 
atus, the  gas  should  be  allowed 
to  flow  freely  through  the  interrupter.  It  is  a  good  practice  to  apply  a 
light  to  the  outlet  tap,  and  allow  the  gas  to  burn  for  a  few  minutes  in 
order  to  expel  all  air  from  the  interior.     It  is  important  to  see  that  the 


Fig.  189. — -Mercury  iuterrupter  with  gas  di-electric. 
(Schall.) 


Fig.  190. — Mercury  interrupter  showing  details. 

interior  of  the  interrupter  is  kept  clean,  and  when  a  considerable  amount 
of  work  has  to  be  done  it  is  well  to  thoroughly  inspect  the  break  at  least 
twice  a  week  and  clean  the  jets  out. 


DIPPER  INTERRUPTER 


271 


Some  makers  claim  for  their  interrupter  that  cleanhig  is  only  necessary 
once  in  six  months,  but  this  is  quite  a  mistake.  Careful  cleaning  at  short 
intervals  facilitates  harmonious  working  of  apparatus. 

Other  forms  of  interrupters  may  be  used,  of  these  the  best  being  the 
electrolytic.  This  break,  if  properly  adjusted,  will  be  found  useful.  It  is 
the  easiest  of  all  interrupters  to  work  with,  requires  very  little  cleaning,  and 
hardly  any  attention  beyond  an  occasional  adjustment ;  it  has  the  further 
advantage  that  the  variations  are  greater.  With  an  adjustable  primary  and 
two  or  more  points  in  the  interrupter,  it  gives  a  wide  range  of  usefulness. 
When  using  very  hard  tubes  it  is  necessary  to  get  a  relatively  large  current 
in  the  primary.  This  it  is  possible  to  obtain  by  using  a  thick  platinum 
point.     A  tachymeter  may  also  be  used  when  desired,  see  Fig.  191. 


Fig,  191. — Dipping  interrupter  with  revolution  counter  or  tachymeter. 


Dipping-  Interrupter  with  Counter,  for  Reg-ulating-  Therapeutic 
Doses. — The  interrupter  illustrated  above  is  designed  chiefly  for  ringworm, 
but  may  be  used  for  other  therapeutic  purposes  of  X-rays  ;  it  is  arranged 
to  give  a  dosage  measured  by  a  definite  number  of  interruptions  in  the 
prijnary  circuit.  For  this  purpose  a  dipper  mercury  interrupter  is  employed, 
the  turbine  forms  not  being  sufficiently  definite,  it  being  difficult  to 
accurately  register  every  interruption  on  the  counter.  The  axle  of  the 
motor  is  directly  connected  with  the  counter,  which  is  provided  with  an 
indicator  and  dial.  The  indicator  is  set  to  the  number  of  interruptions 
the  exposure  is  to  consist  of,  and  the  interrupter  switched  on.  When  the 
indicator  reaches  zero  the  exposure  is  automatically  terminated  by  the 
current  being  cut  ofi  by  a  relay  switch.  There  is  a  timepiece  on  the  circuit, 
and  the  exposures  can  be  calculated  by  time,  allowing  for  so  many  inter- 
ruptions per  minute. 

The  important  thing  in  the  management  of  all  interrupters  is  to  obtain 


272 


EADIATION  THERAPEUTICS 


the  maximum  of  current  through  a  tube  at  a  particular  spark  gap  with  the 
minimum  of  primary  current.  A  little  practice  will  soon  enable  the  worker 
to  adjust  the  points  and  primary  to  suit  the  particular  tube  in  use. 

Valve  Tubes. — The  employment  of  an  electrolytic  interrupter  involves 
the  use  of  valve  tubes  to  cut  out  the  inverse  current,  which  is  always  present 
with  this  interrupter.  Dr.  Reginald  Morton  has  called  attention  to  an  in- 
genious method  of  checking  inverse  current,  described  below. 

The  Morton  Rectifier. 
— This  apparatus  enables 
the  operator  to  dispense 
with  valve  tubes.  It  may 
be  used  with  currents  up  to 
5  milliamperes.  It  should 
prove  to  be  extremely  use- 
ful in  therapeutic  work. 

The  aim  of  the  appar- 
atus is  to  provide  a  satis- 
factory means  of  eliminat- 
ing inverse  current  without 
the  use  of  valve  tubes. 
The  essential  feature  of 
the  apparatus  is  a  switch, 
which  is  mounted  upon 
the  shaft  of  the  inter- 
rupter. It  is  in  this  con- 
nection similar  to  the  mica 
disc  valve  designed  by  Mr. 
Leslie  Miller,  but  in  the 
Morton  apparatus  a  rotary 
conductor  is  made  use  of 
on  the  same  principle  as 
the  rectifier  on  a  Snook 
machine.  The  amount  of 
current  which  can  be 
passed  through  the  high- 
tension  switch  is  practi- 
cally unlimited,  the  only 
factor  at  present  limiting  the  output  being  the  amount  of  energy  which 
can  be  dealt  with  efficiently  by  a  mercury  break.  The  arrangement  of 
the  high-tension  switch  in  relation  to  the  mercury  break  is  shown  in 
Fig.  193,  the  respective  parts  by  similar  letters  on  the  three  figures. 
P  P  are  the  contacts  through  which  the  primary  current  passes  to 
the  coil  when  they  are  connected  together  by  the  revolving  mercury  jet. 
S  S  are  the  high-tension  contacts  connected  in  series  with  the  X-ray  tube 
circuit,  the  conductor  C  being  so  set,  in  relation  to  the  interrupter,  that  the 
whole  of  the  high-tension  current  passes  through  it,  which  is  produced  by  the 


Fig.  192. — -Morton  rectifier  fitted  to  a  coil  outfit,  with  control 
table. 


THE  MORTON  RECTIFIER 


273 


break  of  the  primary  current.  .,.When  the  primary  current  is  made,  a  long  air- 
gap  is  interposed  in  the  secondary  circuit,  which  prevents  the  passage  of  the 
inverse  discharge.  The  apparatus  can  be  arranged  to  give  quick  or  slow 
interruptions,  the  latter  being  particularly  efficacious  when  used  in  thera- 
peutic work,  adjustments  being  provided  to  facilitate  the  use  of  either  type 
of  interruption.  This  arrangement  appears  to  render  the  apparatus  particu- 
larly  applicable   to 

-^ IS 


SI 


NtWTON  Si  WRIGHT  C-" 
1.0ND0M 


"4"'- 


D- 


Fig.  193. — Diasfram  of  connections  for  Morton  rectifier. 


therapeutic  work  of 
the  intensive  form, 
and  the  absence  of 
all  inverse  current 
makes  it  possible 
to  work  without 
valve  tubes.  If 
this  is  borne  out  in 
practice  the  appar- 
atus should  prove 
itself  to  be  of  the 
greatest  possible 
value  to  the  radio- 
therapist. With 
most  mercury 
breaks  this  inverse 
current  is  also  pre- 
sent ;  so,  whichever  type  of  break  is  used  it  is  well  to  have  two  or  more 
valve  tubes  attached  to  the  apparatus.     An  osmosis  regulator  attached  to 

the  valve  tube,  with  a  gas  jet 
which  can  be  regulated  from  a 
distance,  is  very  useful. 

A  triple  valve  tube  will  be 
sufficient  to  check  a  moderate 
amount  of  inverse  current.  This 
should  have  a  regulating  device 
attached  to  it.  A  good  one,  which 
is  now  being  attached  to  a  great 
many  X-ray  bulbs  and  valve  tubes, 
is  that  introduced  by  Bauer  (see 
Fig.  41,  page  46).  These  tubes  are 
capable  of  regulation  from  a  dis- 
tance, a  length  of  rubber  tubing 
being  attached  to  the  air  valve, 
while  at  the  other  end  is  a  small  hand-pump.  By  compressing  the  latter, 
a  small  quantity  of  air  is  allowed  to  pass  into  the  interior  of  the  tube.  This 
lowers  the  vacuum.  This  is  a  good  method  for  the  regulation  of  X-ray  and 
valve  tubes,  but  requires  careful  manipulation  to  ensure  efficient  working. 
The  construction  of  a  valve  tube  and  the  method  of  arranging  one  or 

18 


Fig.  191.  ^Triple  valve  tube  (C.  Andrews). 


274  RADIATION  THERAPEUTICS 

more  in  the  circuit  has  been  described  in  the  section  on  radiography.  What 
has  been  said  there  appHes  equally  to  the  therapeutic  outfit.  With  this 
as  with  all  forms  of  regulators  it  is  important  that  it  should  not  be  used  too 
frequently  or  too  vigorously.  The  vacuum  is  easily  disturbed  and  the  valve 
tube  becomes  too  variable  for  easy  control. 

The  most  convenient  mercury  interrupter  is  probably  a  mercury  jet 
interrupter.  There  are  several  which  are  aU  equally  good.  It  should  be 
possible  to  control  the  speed  ;  a  resistance  should,  therefore,  be  added  for 
the  control  of  the  interrupter.  Another  resistance  is  necessary  to  regulate 
the  amount  of  current  passing  through  the  primary. 

Figs.  198  and  199  represent  convenient  arrangements  for  treatment 
outfit.  The  coil,  spintermeter,  valve  tube,  and  milliamperemeter  are  placed 
on  the  top  of  an  upright  cabinet. 

The  leads  from  the  secondary  may  be  carried  to  a  pair  of  insulated  high- 
tension  steel  cables,  from  which  the  current  is  carried  by  means  of  spring 
cables  to  the  tube  holder. 

On  a  suitable  switchboard,  the  regulating  devices  are  conveniently 
arranged.  A  mercury  jet  break  is  mounted  on  the  base  of  the  cabinet,  while 
above  it,  if  desired,  a  dipper  break  with  an  automatic  tachymeter  may  be 
added  to  the  outfit,  this  latter  instrument  being  useful  when  it  is  necessary 
to  record  accurately  the  number  of  interruptions  in  a  given  exposure.  It 
cannot,  however,  be  relied  on  as  an  absolute  measure  of  the  dose  ;  other 
methods  must  always  be  used  as  well,  in  order  to  get  a  check  observation. 

The  Rhythmeur  Interrupter. — This  is  a  useful  addition  to  the  thera- 
peutic outfit ;  it  is  very  valuable  for  the  deep  treatment  of  tumours,  when 
heavy  currents  require  to  be  passed  through  hard  tubes.  It  is  a  mechanical 
device  by  means  of  which  the  current  is  cut  off  for  a  fixed  period  of  time, 
varying  from  one  to  four  or  more  seconds.  This  allows  the  tube  time  to 
cool  between  the  periods  of  activity. 

On  the  Use  of  Valve  Tubes. — This  has  been  fully  entered  into  in  the 
radiographic  section,  but  a  brief  reminder  of  the  methods  of  connecting  up 
the  valve  tubes  will  be  useful  here.  The  diagrams  on  p.  275  illustrate  two 
methods  of  connecting  the  tubes.  Sometimes,  when  a  considerable  amount 
of  reverse  current  is  present  it  may  be  necessary  to  put  two  or  more  valve 
tubes  in  a  circuit.  They  can  then  be  arranged  on  both  negative  and  positive 
poles. 

The  tube  used  in  X-ray  therapy  should  be  under  the  complete  control 
of  the  operator.  Any  type  of  tube  may  be  used,  but  it  is  important  to  have 
such  control  of  it  that  the  type  of  ray  best  suited  to  a  particular  case  may 
be  produced.  It  is  not  sufficient  simply  to  turn  on  a  switch  with  any  tube 
and  give  a  few  minutes'  exposure  to  the  rays.  That  method  sufficed  in 
the  days  when  little  was  known  of  the  technique  of  X-ray  treatment, 
but  now  we  must  be  able  so  to  manipulate  the  apparatus  that  results  may 
be  obtained  with  a  degree  of  certainty. 

The  elaboration  of  the  installation  has  been  the  necessary  outcome  of 
the  experience  of  individual  workers.     Consequently,  at  the  present  time 


THE  THERAPEUTIC  TUBE  STAND 


275 


we  are  still  far  removed  from  a  standardisation  of  apparatus,  tubes,  and 
dosage.  Before  uniform  results  can  be  turned  out  this  standardisation  must 
become  an  established  fact.  It  has  been  the  aim  of  the  writer  to  reduce, 
so  far  as  is  possible,  all  the  installations  under  his  care  to  a  uniform  standard. 


Fig.  195. — Method  of  connecting  coil  to  valve 
tube  and  X-ray  tube.  Valve  tube  on  positive 
pole  (Siemens). 


Fig.  196. — Method  of  connecting  coil  to  tube. 
Valve  tube  on  negative  pole. 


Fig.  197. — Tube  stand  for  deep  therapeutic  work. 
(Schall.) 


The  Therapeutic  Tube  Stand.— Any  simple  stand  will  suffice  for 
therapeutic  work,  but  it  must  have  good  mechanical  movements.  One  of 
the  best  is  made  by  GaifEe  of  Paris.  The  tube  may  be  adjusted  readily 
to  any  angle,  and  the  movements  are  as  perfect  as  mechanical  ingenuity  can 
make  them.  The  only  drawback  to  the  stand  is  that  only  half  of  the  tube  is 
enclosed,  and  the  lead  glass  is  frequently  not  thick  enough  to  ensure  complete 
protection.  The  stand  should  have  a  number  of  extension  tubes  of  various 
sizes,  and  should  have  also  a  tripod  applicator  for  ringworm  treatment. 


276 


RADIATION  THERAPEUTICS 


The  under  aspect  of  the  tube  box  should  have  a  slot  into  which  the  filters  can 
easily  be  placed,  and  a  complete  set  of  filters  should  go  with  each  stand. 
The  aluminium  filters  should  range  from  -^  up  to  3  mm.  in  thickness.  In 
hospitals,  especially,  these  parts  should  be  easily  sterilisable.  The  tube 
stand  should  also  have  a  holder  for  the  pastille. 

Dr.  Gauss  of  Freiburg  has  introduced  a  stand  (Fig.  197)  designed  for 
tubes  which  are  to  be  used  with  a  very  heavy  current.  It  is  so  arranged  that 
the  distance  of  the  tube  from  the  surface  of  the  body  can  readily  be  regulated 
and  measured.  In  addition  to  this  it  has  a  number  of  good  mechanical 
movements,  which  render  its  use  a  great  acquisition  to  the  operator.  The 
tube  box  is  protected  by  thick  lead  glass  and  lead  rubber.  This  is  necessary 
on  account  of  the  very  hard  tubes  required  for  the  treatment  of  deep-seated 
organs. 

A  treatment  couch  should  move  easily,  and  the  top  should  be  covered 
with  leather  or  some  sterilisable  material.     A  hinged  top  on  the  couch  is 


GAIFFE     ROCHEFORT     TRANSFORMER 


VALVE     TUBE 


SPINTER      METER 

RECULATED     FROM    INSIDE    OF    CABIN 


MILUI     AMPERE     METER 


CREVILLE  -  READ    PROTECTIVE    SHIELD 


AMPERE     METER 
PILOT     LAMP 
MINUTE     METER 
-AUTOMATIC     TIME    SWITCH 
LECTRIC    SIGNAL    BELL 
RHEOSTAT    FOR    COIL   REGULATION 
RHEOSTAT  FOR   MOTOR   REGULATION 
GREVILLE    GAIFfE    MERCURY   &  CAS 
INTERRUPTER 


Fig.  198. — A  convenient  arrangement  of  apparatus  for  therapeutic  work. 


an  advantage.     A  treatment  chair  is  a  valuable  addition  to  the  thera- 
peutic department,  and  should  have  a  movable  head-rest,  with  side-clips 


ARRANGEMENT  OF  APPARATUS 


277 


for  fixing  the  liead.     It  will'  be  found  most  useful  where  children  are  being 
treated,  as  the  head  may  be  fixed  without  discomfort  to  the  patient. 

Further  Points  on  the  Arrang-ement  of  Apparatus.— It  will  be 
found  to  be  a  convenience  to  have  all  the  parts  of  the  apparatus  which  are 
likely  to  get  out  of  order  in  an  accessible  position  in  the  room  ;  and  all  parts 


Fig.  199.- 


-Apparatus  arranged  ou  an  iipright  cabinet. 
(Watson  &  Sons.) 


Fig.  200. — Diagram  to  show  arrangement  of 
apj)aratus  on  an  upriglit  cabinet. 


subject  to  variations  should  be  readily  controlled.  It  should  be  possible  to 
darken  the  room  if  desired.  This  is  not  essential  for  therapeutic  work, 
though  it  is  a  distinct  advantage  to  be  able  to  darken  the  room  so  as  to 
observe  how  the  tube  is  running. 

The  leads  from  the  terminals  of  the  coil  may  be  connected  to  the  tube  by 
means  of  insulated  or  spring  cables.  It  is  convenient  to  have  two  steel  wires 
carried  across  the  room  at  a  convenient  height.  These  should  be  insulated 
at  the  points  of  insertion  into  the  walls.  Two  spring  cables  on  trolley  wheels 
carry  the  current  to  the  X-ray  tube.     The  leads  from  the  terminals  of  the  coil 


278  RADIATION  THERAPEUTICS 

are  connected  to  the  overhead  wires.  This  arrangement  facilitates  the 
adjustments  of  the  tube  stand  and  allows  of  a  rapid  change  from  one  ap- 
paratus to  another.  Most  of  the  newer  tube  stands  are  provided  with  an 
efficiently  protected  tube  box.  The  tube  is  placed  in  the  tube  box  or  holder, 
and  connected  up  to  the  coil  and  valve  tubes.  The  anode  of  the  coil  is 
connected  to  the  anode  of  the  tube,  and  cathode  to  cathode  (see  Fig.  195). 
Valve  tubes  should  be  provided  in  all  installations  when  a  coil  is  used,  and 
it  will  be  an  advantage  to  have  an  oscilloscope  tube  in  the  circuit.  This 
should  be  placed  at  some  distance  from  the  coil  if  reliable  observations  are 
to  be  made.  An  oscilloscope  in  the  near  vicinity  of  a  large  coil  often  acts 
inefficiently  owing  to  its  proximity  to  the  magnetic  field  of  the  coil. 

Testing"  the  Apparatus  before  using-  for  Treatment. — The  maui 
switch  should  be  turned  on  with  a  minimum  current  at  first,  and  the  tube 
observed  as  to  style  of  running,  colour,  etc. ;  then  the  current  may  be  gradu- 
ally increased.  The  penetration  of  the  tube  is  tested  by  a  radiometer,  or  by 
the  alternative  spark-gap — a  rough  but  very  useful  indication  of  the  hard- 
ness of  a  tube.  The  qualimeter  of  Bauer  may  also  be  used  for  this  purpose, 
and  is  to  be  preferred  when  many  observations  require  to  be  made. 

A  note  of  the  amperage  in  the  primary  should  be  made  and  of  the  current 
passing  through  the  miUiamperemeter.  These  are  most  important  points  on 
which  the  calculation  of  the  exposure  is  based.  There  are,  however,  other 
factors  which  must  be  considered  in  detail. 


Methods  used  in  Estimation  of  Dosage 

At  the  very  outset  we  are  met  with  the  difficulty  of  estimating  even 
approximately  the  dosage.  Many  methods  are  employed,  none  of  them 
perfect.  Tubes  vary  from  day  to  day  in  spite  of  the  great  improvements 
which  have  taken  place  of  recent  years.  The  various  systems  of  measuring 
the  X-ray  dosage  will  be  described  in  detail.  At  present  there  is  no  standard- 
isation of  dosage,  and  until  this  is  obtained,  it  is  best  for  an  operator  to 
understand  thoroughly  one  good  method  and  to  work  steadily  with  it.  A 
knowledge  of  the  others  is  useful,  but  it  is  hopeless  to  try  to  combine  several 
different  methods. 

An  erythema  dose  is  one  which  causes  slight  erythema  to  appear  within 
fifteen  to  twenty-one  days.  Four-fifths  of  an  erythema  dose  will,  in  the 
majority  of  cases,  cause  the  hair  to  fall  out.  This  dose  has  been  found  to 
cause  a  change  in  the  colour  of  certain  chemical  substances. 

Two  methods  may  be  described  :  (1)  The  indirect,  and  (2)  the  direct. 
These  two  should  always  be  used  together,  the  indirect  being  a  good  check 
on  the  direct. 

In  the  Indirect  Method  the  miUiamperemeter  is  used  to  measure,  not 
the  rays,  but  the  quantity  of  current  passing  through  the  tube  ;  and  the 
number  of  milliamperes  multiplied  by  the  volts  used  gives  the  quantity  of 
X-rays  generated  in  the  tube. 


METHODS  USED  TO  ESTIMATE  DOSAGE  279 

The  quantity  of  X-raysteceived  by  the  object  depends  on  (a)  the  quan- 
tity of  X-rays  generated  ;  (6)  the  distance  between  the  tube  and  the  object ; 
(c)  the  time  of  the  exposure  ;   (d)  the  sensitiveness  of  the  object. 

The  reading  of  the  milhamperemeter  must  therefore  be  supplemented 
by  those  other  factors  before  we  can  estimate  the  dose  received. 

The  distance  has  a  great  influence,  because  the  intensity  of  the  X-rays 
diminishes,  like  that  of  ordinary  light,  as  the  square  of  the  distance  increases. 
A  strip  exposed  40  cms.  from  the  anticathode  requires  four  times  as  many 
milliampere  seconds  to  assume  tint  5  x  as  a  strip  exposed  at  a  distance 
of  20  cm. 

Reverse  Currents. — The  presence  of  reverse  currents  may  cause  an 
under-exposure,  because  milliamperemeters  of  the  d'Arsonval  type  do  not 
indicate  alternating  currents  if  both  phases  are  of  equal  strength. 

If  one  phase  preponderates,  as  will  be  the  case  if  the  reverse  current 
from  the  spark-coil  becomes  so  strong  that  it  can  discharge  through  the 
tubes,  the  milhamperemeter  indicates  only  the  difierence  between  the  break- 
ing and  the  closing  current ;  the  stronger  the  reverse  current  the  greater 
will  be  the  error.  With  good  modern  coils  there  should  be  practically  no 
reverse  current  with  the  weak  or  moderate  currents,  say  up  to  6  milliamperes, 
which  are  employed  in  the  majority  of  exposures,  but  when  currents  of  10 
milliamperes  and  more  are  employed,  some  reverse  current  begins  to  appear 
even  with  the  best  of  coils. 

If  the  coils  are  old  or  badly  constructed,  or  if  interrupters  with  high- 
frequencies  are  used,  reverse  currents  may  be  present  even  when  1  milhampere 
only  is  used.  The  oscilloscope  tubes,  which  indicate  the  presence  and 
intensity  of  reverse  currents,  are  not  expensive,  and  can  easily  be  inserted 
in  the  circuit  with  a  milliamperemeter.  They  should  be  used  if  there  is 
any  doubt  about  the  presence  of  reverse  current,  and  if  it  exists  it  should 
be  suppressed  by  means  of  a  spark-gap,  or  by  means  of  a  valve  tube,  as 
otherwise  the  milliampere  method  will  give  wrong  results. 

Another  error  may  arise  if  the  glass  of  the  tube  is  unusually  thick.  It 
is  not  likely  that  this  will  cause  much  difference,  because  the  glass  bulb 
absorbs  the  softest  ray  only.  Another  error  may  arise  if  the  penetrating 
power  of  the  tube  changes  during  the  exposure.  The  milHamperemeters 
are,  however,  the  best  and  most  convenient  indicators  of  any  such  changes. 
The  Bauer  qualimeter  also  indicates  these  variations. 

The  Direct  Method.— The  total  quantity  of  X-rays  received  by  an 
object  can  be  measured  by  various  methods  introduced  by  Holzknecht, 
Sabouraud,  Kienbock,  Bordier,  Hampson,  and  others.  The  method  most 
used  in  this  country  is  that  introduced  by  Sabouraud  and  Noire.  The 
principle  is  the  same  as  that  of  several  others,  and  depends  upon  the  action 
of  X-rays  and  similar  agents  upon  a  disc  of  barium  platino  cyanide,  the 
same  material  that  is  used  for  the  fluorescent  screen.  These  discs  and 
similar  agents  are  known  as  chromo-radiometers,  because  of  the  change  of 
colour  which  occurs  when  they  are  exposed  to  the  action  of  rays. 

The  discs  should  be  exposed  on  a  thin  sheet  of  metal  at  a  distance  from 


280  RADIATION  THERAPEUTICS 

tlie  anticathode  equal  to  half  the  distance  between  the  anticathode  and  the 
skin  of  the  patient ;  and  they  should  be  protected  from  the  action  of  day- 
light. The  change  of  colour  takes  place  gradually  under  the  action  of  X-rays, 
the  green  colour  changing  to  a  brown.  The  discs  discolour  in  the  same  way 
whether  exposed  to  an  X-ray  tube,  an  incandescent  electric  lamp,  or  to  sun- 
shine, or  when  heated  in  a  flame  from  a  spirit  lamp. 

When  the  pastilles  are  exposed  to  the  X-rays,  the  apple-green  colour 
changes  gradually  to  red  and  red-brown,  and  by  experiment  the  exact  tint 
was  found  which  the  pastilles  assumed  after  exposure  to  a  dose  which  caused 
the  hair  to  fall  out.  This  is  called  tint  B,  and  a  tablet  showing  this 
colour  is  supplied  with  every  booklet  of  Sabouraud  pastilles.  If  an  ex- 
posure of  eight  minutes  caused  the  pastille  to  assume  tint  B,  another  two 
minutes'  exposure  will  cause  an  erythema  to  appear  after  an  interval. 
Where  the  dose  is  judged  by  the  pastille  alone  the  tint  B  in  the  booklet 
should  always  be  used  for  pastilles  used  from  the  particular  booklet. 
This  is  not  necessary  when  Hampson's  or  Lovibond's  radiometers  are 
used. 

These  pastilles  are  not  very  sensitive,  and  to  obtain  a  sufficiently  great 
change  in  colour  they  have  to  be  exposed  at  half  the  distance  existing 
between  the  anticathode  and  the  object,  so  that  they  receive  four  times  the 
quantity  of  X-rays  which  the  object  receives.  Nevertheless,  quite  large 
errors  are  often  made  by  different  observers  in.  comparing  these  small  shades 
of  colour.  The  pastilles  are  sensitive  to  heat,  so  there  should  be  a  distance 
of  at  least  2  cm.  between  the  tube  and  the  pastille,  or  the  heat  of  the  glass 
tube  may  prematurely  discolour  the  pastille.  Daylight  restores  the  colour 
to  the  pastilles.  They  must,  therefore,  be  protected  from  bright  light  during 
the  exposure,  and  compared  with  the  standard  tint  in  a  light  weak  in  actinic 
rays,  e.g.  the  light  of  an  incandescent  lamp. 

Great  care  must  be  exercised  in  estimating  the  degree  of  change  in  the 
colour,  and  it  must  be  noted  that  a  marked  difference  exists  between  the 
shade  of  colour  of  the  disc  when  it  is  examined  in  daylight  and  when  it  is 
examined  m.  artificial  light.  A  serious  error  in  dosage  may  easily  be  made  if 
this  difference  is  overlooked. 

These  pastilles  have  proved  very  useful  in  the  estimation  of  dosage  in 
the  treatment  of  ringworm  and  superficial  skua  lesions,  and  they  are  almost 
universally  used  in  the  treatment  of  this  first  disease.  A  large  measure 
of  the  success  of  the  treatment  of  ringworm  by  X-rays  depends  upon  the 
after  treatment,  and  where  the  children  cannot  be  under  constant  super- 
vision it  is  very  necessary  to  issue  concise  and  definite  instructions  to  the 
parents. 

The  several  precautions  which  should  be  taken  are  dealt  with  later  on. 
When  using  Sabouraud  pastilles,  a  weak  dayUght  is  recommended,  and  for 
Holzknecht  and  Bordier  pastilles  the  light  of  an  incandescent  lamp.  When 
using  these  pastilles  to  measure  dosage,  a  definite  system  of  examination 
should  be  carried  out  in  all  cases.  The  time  taken  to  change  a  pastille 
from  the  A  to  the  B  tint  by  the  tube  in  use  should  be  ascertained.     Then 


THE  USE  OF  THE  SABOURAUD  PASTILLE  281 

during  an  exposure  of,  say,  teh  minutes,  the  pastille  should  be  examined  at 
least  three  times. 

The  first  examination  should  be  at  the  end  of  four  minutes.  This 
will  show  whether  the  rays  from  the  tube  are  acting  on  the  pastille.  If 
by  any  chance  the  tube  is  acting  too  quickly,  a  full  dose  may  be  given 
in  less  than  half  the  time  usually  required,  but  this  early  examination 
makes  it  possible  to  avoid  serious  damage  to  the  patient.  Tow^ards  the 
end  of  the  exposure  the  inspections  should  be  more  frequently  made. 
Stress  is  laid  upon  this  point  here  because  recently  in  the  experience 
of  several  workers  vagaries  of  the  tube  undetected  at  the  time  have 
led  to  the  administration  of  excessive  doses  in  less  than  half  the  time 
usually  taken  by  the  tube  to  colour  the  pastille.  These  untoward  results 
have  also  been  obtained  when  to  all  appearances  the  tube  was  working 
properly  and  the  pastille  was  under-  rather  than  over-done.  No  system  of 
measuring  X-ray  dosage  is  perfect,  and  whichever  one  is  employed  should 
always  be  checked  by  the  indirect  method.  A  Bauer  qualimeter  on  the 
negative  pole  gives  an  approximate  idea  of  the  hardness  of  the  tube.  It  is 
not  absolute,  but  as  a  guide  to  the  steadiness  of  the  tube  it  is  very  valuable. 
The  milliamperemeter  records  the  current  in  the  secondary  circuit  and 
approximately  the  amount  of  current  passing  through  or  around  the  tube. 
The  alternate  spark-gap  also  gives  an  indication  of  the  hardness  of  the  tube, 
and  should  be  tested  from  time  to  time.  Lastly,  there  is  the  tube  itself.  A 
careful  watch  kept  upon  it  should  enable  the  operator  to  judge  of  its  condi- 
tion. Experienced  workers  can  tell  the  variations  in  hardness  by  the  sound 
a  tube  makes  when  running.  Some  can  tell  approximately  the  exposure  by 
the  same  means,  i.e.  appearances  of  the  tube,  sound,  etc.,  but  for  an  X-ray 
dosage,  strict  attention  to  detail  and  the  carefid  watching  of  all  the 
conditions  should  be  insisted  upon. 

The  pastilles  should  be  compared  immediately  the  exposure  has  been 
terminated,  as  the  colour  should  settle  the  time  of  the  exposure  ;  if  left  for 
comparison  till  some  time  after,  the  pastille  will  be  found  to  have  faded. 
The  same  pastille  should  not  be  used  more  frequently  than  three  or  four  times. 
Sabouraud  pastilles  show  correctly  when  used  with  medium  tubes,  but  with 
hard  tubes  there  is  a  tendency  to  under-exposure,  tint  B  being  reached  a 
little  too  early,  and  with  soft  tubes  there  is  a  tendency  to  over-expose,  as 
tint  B  is  reached  a  little  too  late. 

In  the  booklet  supplied  by  Messrs,  Sabouraud  and  Noire  with  the 
pastilles  tint  A  represents  the  pastille  before  it  is  exposed  to  the  X-rays. 
Tint  B  represents  the  same  pastille  after  it  has  received  exposure  to  the 
X-rays,  corresponding  to  the  maximum  dosage  which  the  human  skin  is 
able  to  receive  without  producing  erythema,  radiodermatitis,  or  a  permanent 
alopecia. 

Holzknecht's  Quantimeter. — For  this  instrument,  barium  platino 
cyanide  pastilles  are  also  used,  but  they  are  compared  with  unexposed 
pastilles  of  the  same  material  arranged  under  a  celluloid  film  of  red-brown 
colour,  increasing  gradually  in  intensity.     By  moving  the  exposed  pastilles 


282  KADIATION  THERAPEUTICS 

along  this  film,  the  discoloration  caused  by  |,  |,  etc.,  of  an  erythema  dose 
can  be  measured. 

Dp.  Bordier's  Chromo-radiometer. — This  chromo-radiometer  depends, 
like  Sabouraud's,  on  the  discoloration  of  pastilles  of  barium  platino  cyanide, 
but  the  scale  shows  five  different  tints  for  comparison,  instead  of  the  single 
one  of  Sabouraud's  instrument.  Bordier's  pastilles  have  to  be  attached  to 
the  skin  of  the  patient.  The  pastilles  should  be  compared  with  the  scale  or 
"  Teinte  B  "  by  the  light  of  a  match,  a  candle,  a  benzine  lamp,  or  other 
artificial  light  of  slight  actinic  power.  The  distance  between  the  pastilles 
and  the  glass  wall  of  the  tube  should  never  be  less  than  2  cm.,  to  prevent 
their  being  discoloured  by  the  heat  of  the  tube.  The  pastilles  are  most 
accurate  when  used  with  tubes  of  medium  penetrating  power.  With  soft 
tubes  they  tend  to  indicate  a  smaller  dose,  with  hard  tubes  a  larger  dose 
than  actually  given. 


Fig.  201. — Complete  Kienbock  quantimeter.     (Schall. ) 

The  Kienbock  Quantimeter, — This  method  is  based  on  the  discolora- 
tion of  bromide  of  silver  under  the  influence  of  X-rays.  Compared  with  the 
chromo-radiometer  of  Holzknecht  or  Sabouraud,  it  has  the  advantage  that 
it  is  more  sensitive,  gives  more  subdivisions,  leaves  a  permanent  record, 
and  is  cheaper.  Its  only  disadvantage  is  that  the  results  can  only  be  read 
ofi  after  a  strip  of  sensitive  paper  has  been  developed,  a  process  which 
occupies  one  minute.  There  is  no  need  to  resort  to  a  dark  room,  as  with  the 
help  of  a  small  light-tight  box  the  development  can  be  done  in  daylight  in 
the  consulting  room. 

The  apparatus  consists  of : 

1.  Strips  of  bromide  of  silver  paper  measuring  |  inch  by  2^  inches, 
enclosed  in  small  light-tight  envelopes.  The  envelopes  bear  a  label  to  be 
filled  up  with  the  name  of  the  patient,  date,  and  duration  of  the  exposure. 
Envelope  and  strip  bear  identical  numbers. 

2.  A  standard  scale  in  wooden  case,  containing  eight  different  tints  of 
the  colours  which  the  bromide  of  silver  will  assume  gradually  under  prolonged 


KIENBOCK  QUANTIMETER 


28J 


influence  of  the  X-rays.     A  runner  with  glass  window  slides  along  the  scale, 
and  the  developed  strips  are  placed  into  this  frame. 

3.  A  set  of  four  test  tubes  of  2  inches  diameter  and  2  inches  length,  in 
small  metal  stands. 

A  convenient  addition,  when  a  dark  room  is  not  available,  is  a  dark  box, 
which  enables  the  operator  to  develop  the  strips  in  the  consulting  room. 
This  box  has  room  for  the  stand  holding  the  test  tubes,  in  which  develop- 
ment, washing,  and  fixing  take  place.  It  is,  however,  much  better  to  develop 
the  strips  in  a  dark  room. 

Arrangements  for  Exposure. — One  or  several  strips  of  the  sensitive  paper 
are  placed  on  the  part  to  be  treated ;  they  absorb  practically  no  X-rays. 
The  side  of  the  envelope  bear- 
ing the  label  must  face  the 
patient's  skin.  If  the  total  dose 
is  to  be  administered  in  several 
sittings,  the  same  strip  is  always 
exposed  again,  so  that  the  sum 
total  of  the  rays  reaching  the 
patient  will  also  reach  the  strip. 
If  many  sittings  with  short  ex- 
posures are  to  be  given,  it  is 
convenient  to  use  more  than  one 
strip  ;  one  is  left  to  record  the 
total  sum,  and  of  the  other, 
parts  are  cut  off  from  time  to 
time  to  make  test  developments. 

The   number    of    the   strip, 
and  other  remarks,  are  immedi- 
ately entered  into  the  case  book,  where  also  the  strip  is  stuck  when  it  has 
been  washed  and  dried. 

Development. — In  order  to  find  out  the  quantity  of  X-rays  which  has 
been  administered,  the  strip  has  to  be  developed. 

The  developer  consists  of  two  stock  solutions,  A  and  B,  mixed  in  proper 
proportions  with  distilled  water,  and  made  up  as  follows  : 

A  B 


Fig.  202. — Arrangement  of  apparatus  and  paper  when 
rising  Kienbcick's  method  of  estimating  dosage. 


Distilled  water        .        .      1000  c.c.                   Distilled  w 

-ater 

1000  c.c. 

Sulphite  of  soda     .        .        150  grammes         Potassium 

carbonate     . 

110  grammes 

Metol  (Hauff)  ...         15         „ 

FIXING  SOLUTION 

Distilled  water     .... 

1000  c.c. 

Sulphite  of  soda 

20  grammes 

Tartaric  acid       .... 

10 

Hyposulphite  of  soda    . 

200 

Great  care  must  be  taken  in  preparing  the  solutions ;   it  is  essential 
that  the  bottles  shall  be  absolutely  clean,  and  that  distilled  water  shall  be 


284 


RADIATION  THERAPEUTICS 


used  throughout.     The  developer  should  never  be  used  when  it  has  become 
stale. 

An  alternative  developer  consists  of  a  stock  solution,  made  up  as  follows  : 


Metol 

Hydro  quinone         .... 
Sodii  sulphite  .... 

Carbonate    ..... 
10  per  cent  solution  of  potassium  bromide 
Distilled  water        .... 


1  gramme 
4  grammes 

50 

50 
4  CO. 
500  CO. 


The  fixing  solution  is  made  up  as  follows 

Hypo 

Water  ...... 

Potassium  meta-bisulphite 


400  grammes 
1000  c.c. 
25  grammes 


Each  box  of  strips  is  furnished  with  a  set  of  instructions  regarding  the 
duration  of  development,  and  these  must  be  carefully  observed. 

It  is  not  always  possible  to  make  succeeding  batches  of  strips  of  exactly 
the  same  degree  of  sensitiveness ;  therefore  each  new  batch  is  carefully 
tested,  and  if  necessary  a  new  scale  of  tints  is  prepared.  Each  strip  is  marked 
with  a  letter,  and  must  only  be  compared  with  a  scale  bearing  the  same 
letter. 

The  first  of  the  four  test  tubes  is  filled  with  the  developer  mentioned 
above,  the  second  is  filled  with  water,  the  third  with  fixing  solution,  and  the 
fourth  again  with  water.     The  strips  are  taken  out  of  the  envelope  either  in 

the  dark  room  or  in  the 
dark  box  mentioned 
above,  and  are  immersed 
in  the  developer  for  a 
certain  time,  as  stated 
on  the  instructions  with 
the  strips.  The  strip 
must  be  kept  in  motion 
while  in  the  developer. 
The  same  developer  can 
be  used  for  several  strips, 
but  it  deteriorates  gradu- 
ally in  contact  with  air. 
As  in  photography,  great 
care  must  be  taken  that 


Fig.  203.— Developing  the  strips. 


the  developer  is  not  contaminated  with  hypo,  and  it  must  be  at  the 
temperature  stated  on  the  instructions  (18°  C),  because  too  cold  a  developer 
produces  far  too  light  a  tint.  After  development,  the  strip  is  washed  for  a 
few  seconds  in  the  second  glass,  and  transferred  into  the  third  glass  contain- 
ing the  fixing  solution.  It  ought  to  remain  in  this  not  less  than  a  minute, 
but  if  it  remains  longer  no  harm  is  done.  Then  it  is  rinsed  in  the  fourth 
glass,  and  is  ready  for  comparison  with  the  standard  scale.    (It  need  not  be 


KIENBOCK  QUANTIMETER 


285 


dry  for  this  purpose.)  To  lesive  a  permanent  record,  the  strip  has  to  be 
washed  like  any  print  for  about  half  an  hour  in  several  changes  of  water. 
Several  strips  may  be  developed  or  fixed  simultaneously  by  using  a  large 
enough  vessel. 

The  Standard  Scale  consists  of  nine  different  tints,  marked  0,  \,  1,  2, 
3,  4,  5,  7,  10.  The  tint  marked  1  is  to  be  considered  the  unit,  and  is  denoted 
by  1  X.  It  is  half  the  value  of  the  dose  required  to  produce  one  unit  in 
the  Holzknecht  Chromo-radiometer,  and  one-tenth  of  the  Sabouraud-Noire 
Tint  B  dose. 

We  therefore  have  : 

10  X  (Kienbock)  =  5  H  (Holzknecht)  =  1  B  (Sabouraud-Noire). 

If  it  is  intended  to  administer  the  maximum  dose  in  one  sitting,  it  will 
be  a  convenience  to  expose  two  strips  of  paper  simultaneously.  When, 
measuring  the  current  passing  through  the  tubes  with  a  suitable  milliampere- 
meter  or  judging  the  degree  of  fluorescence  by  experience,  it  is  found  that 
the  maximum  dose  desired  has  been  nearly  reached,  the  exposure  is  inter- 
rupted for  a  few  minutes  to  develop 
one     strip    and    compare    it    with    the 


Fig.   204. — Comjjarmg  the  wet  strip  with  the 
standard  scale,  wsma,  the  slide. 


Fig.   205. — Comparison  of  the  dry  strip 
without  the  slide. 


standard  scale.  If  it  took  ten  minutes  to  produce  tint  No.  5,  then  it  will 
require  another  two  minutes  to  bring  it  to  tint  No.  6  ;  or  if  it  took  nine 
minutes  to  impart  to  the  strip  the  colour  of  tint  No.  6,  it  will  take  another 
six  minutes'  exposure  to  bring  it  to  a  colour  similar  to  tint  No.  10  (provided 
that  the  condition  of  the  tube  has  not  altered  materially). 

As  it  is  not  possible  to  read  the  value  of  the  dose  directly  from  the  quanti- 
meter  strip  during  the  irradiation,  it  is  advisable  to  measure  the  dose  at  the 
same  time  by  observing  the  milliamperemeter,  and  timing  the  duration  with 
a  watch,  or  it  may  be  checked  by  using  at  the  half-distance  a  Sabouraud 
pastille.  A  second  pastille  may  be  placed  on  the  skin  and  checked  by  means 
of  a  Hampson  or  Lovibond  radiometer. 


286 


KADIATION  THERAPEUTICS 


If  it  is  desired  to  ascertain  tlie  quantity  of  X-rays  which  have  reached 
a  certain  depth,  a  piece  of  aluminium  1  mm.  thick  is  laid  on  part  of  the 
strip.  It  has  been  found  that  this  absorbs  as  much  of  the  X-rays  as  a  layer 
1  cm.  thick  of  skin,  fat,  and  muscles  will  absorb.  In  such  a  case  the  de- 
veloped strip  will  show  two  different  tints  :  the  darker  one  indicates  the 
quantity  of  rays  received  by  the  surface  of  the  skin  ;  the  lighter  tint  records 
the  quantity  of  rays  which  have  penetrated  to  a  depth  of  1  cm.  below  the 
skin.  Strips  of  aluminium  are  supplied  also  which  help  to  find  the  effect 
produced  at  1,  2,  or  3  cm.  depth.  If  the  effect  is  desired  on  the  skin  only, 
it  is  advisable  to  use  medium  tubes,  No.  8  Wehnelt ;  if  deeper  lying  parts 
have  to  be  treated,  it  is  necessary  to  take  tubes  No.  10  or  11  Wehnelt.  It 
is  an  advantage  to  bring  the  tubes  rather  close  to  the  skin  (distance  8  to 
18  cm.)  :  for  treating  ringworm,  15  cm.  ;  for  treating  ovaries,  18  to  25  cm. 
It  is,  however,  often  necessary  nowadays  to  give  doses  far  larger  than 
10  a?  in  a  single  sitting  for  the  treatment  of  fibroids  or  malignant  disease.     As 

the  strips  would  become 
far  too  dark  for  com- 
parative readings  to  be 
made  under  these  circum- 
stances, a  second  scale 
has  been  prepared,  in 
which  tints  are  shown 
which  are  obtained  on 
strips  exposed  under  a 
block  of  aluminium  10 
mm.  thick.  In  this  way 
the  action  on  the  strip  is 
lessened  and  the  latter 
does  not  become  so  dark, 
although  large  doses  are 
given.     Quantities  up  to 


Fig.  206.  — Plain  strips,  exposed  and  developed. 


Fig.  207. — Strips  exposed  with  1 
aluminium  a  ad  develojDed. 


30  or  40  X  can  be  con- 
veniently estimated.  The 
comparison,  develop- 
ment, etc.,  of  the  strips 
is  exactly  the  same  as  if 
the  10  mm.  aluminium 
were  not  used.  The  dose 
which  the  strip  then 
shows  is  that  which  has 
been  applied  at  the  sur- 
face, and  not,  as  is  some- 
times assumed,  that  which 
has  reached  10  cm.  depth. 
The  strips  should  be  compared  with  the  standard  scale  and  a 
record  kept  of  all  exposures  given,  with  the  total  dose  for  each  complete 


Dose  at 


Dose  at  1 
cm.  depth 


Dose  at  3 
cm.  depth 


Envelopes 

containing 

strip  and 

arranged 

with 
aluminium 

step 

1  mm., 

2  mm. , 
and  3  mm. 


Fig.    208. — Strips  exposed  -with 
minium  ladder  and  developea. 


alu 


EECORDING  OF  X-RAY  EXPOSURES 


287 


treatment.  The  method  of  recording  these  data  will  vary  with  each  opera- 
tion. A  record  sheet  should  be  reserved  for  each  patient,  and  all  particulars 
of  treatment  entered  on  it.     A  portion  of  the  developed  paper  may  be 


Medical  Aitend»ni 


Name M  ..  0.^.13*4^^ _ 

Addresi ^ifcl^L^.'taacrJxa.lvat. 

Record    of    X     Ray     Exposures 


ilk-mejcLLca.  


^ 


.3.  Ilf 


11.3     114- 

11.3   IW 

19.3.114. 

35.3. lif 
30.  3.  \k 
(t.  k.  \W 
16.  If.  llf 


(..5.  IW 
iq.  6.  Ik 


of 
Tube 


Exposure 
Mm         Sec 


s 

s 
s 

7 


Amp 


5 
5 

1+' 

W 

b' 
S 
5 
5 
u- 
% 

5 


5 

3 

^1 


CU«x9 


wnarrv;OTTi 

3 
3 
3 
3 


iW, 


'.l»n<mq-. 


^m.T 


Ik)  (>«.1><^ 


10 


int»ft/Tj!t  wj*-iwnj  -ur^it. 


Vff-*-iyvvTii-. 


Fig.  209. — Chart  of  X-ray  exposures,  to  show  method  used  in  recording  dosage  by  Kienbock's 

method. 

Chamois  is  used  as  a  secondary  filter,  and  the  figures  in  that 

column  refer  to  the  thickness  of  aluminium  used. 

arranged  opposite  each  dose,  and  its  numerical  value  placed  alongside.  This 
enables  the  operator  to  calculate  rapidly  the  total  of  the  exposures.  All  the 
other  data  of  exposure  should  also  be  recorded.  Fig.  209  illustrates  a  good 
method  used  for  recording  the  dosage. 

The  lonto  Quantimeter. — This  instrument  has  been  designed  by  Dr. 
Szillard  of  Paris.  An  electrometer  and  a  small  static  machine  to  charge  it 
are  enclosed  in  a  small  case,  and  a  needle  moving  over  a  scale  indicates  the 
degree  of  the  charge.     A  flexible  rubber  tube,  which  encloses  a  conductor. 


288 


RADIATION  THERAPEUTICS 


leads  from  the  electrometer  to  a  small  ionising  chamber,  which  contains  one 
electrode  connected  with  the  electrometer,  and  a  second  one  connected  to 
earth. 

It  is  necessary  that  the  insulation  should  be  perfect,  so  that  surface 
leakage  owing  to  dampness  cannot  take  place.  When  the  X-rays  reach  this 
ionising  chamber  the  electrometer  begins  to  discharge,  and  the  index  of  the 
needle  moves  from  0  towards  10. 

The  division  of  the  scale  has  been  calibrated  to  agree  with  the  Kienbock 
quantimeter.  When  the  needle  reaches  10,  the  ionising  chamber,  which 
can  be  exposed  on  the  skin  of  the  patient,  has  received  a  full  erythema 
dose.  The  instrument  is  so  sensitive  that  half  an  x,  i.e.  the  twentieth  part 
of  an  erythema  dose,  can  be  measured.  The  degree  of  ionisation  varies  with 
the  penetrating  power,  and  the  instrument  can  be  calibrated  for  various 
degrees  of  it  by  placing  diaphragms  of  lead  over  the  ionisation  chamber,  so 
that  the  area  exposed  to  the  influence  of  the  X-rays  can  be  made  larger  or 
smaller.  The  instrument  is  new,  and  its  practical  value  has  yet  to  be  proved. 
In  theory  it  is  certainly  good. 

Lovibond's  Tintometer  (perfected  by  Dr.  Dudley  Corbett)  provides  a 
very  accurate  method  of  estimating  the  degree  of  coloration  of  the  Sabouraud- 


FiG.  210. — Lovibond's  tintometer,  adapted  and  standardised  for  the  accurate  measurement  of 
the  colour-changes  in  the  Sabourand- Noire  pastille  by  Dr.  Dudley  Corbett.  (The  Tinto- 
meter, Ltd.) 


Noire  pastille.  The  apparatus  consists  of  a  tube  or  oblong  viewing  box, 
divided  into  two  by  a  vertical  partition,  so  that  on  looking  through  the 
eye-piece  against  the  background  two  small  white  circles  are  seen.  At  the 
distant  end  of  the  box  are  frames  provided  for  the  insertion  of  the  glass 
standards  ;  on  the  right  for  the  colour  tints,  and  on  the  left  for  a  neutral  tint 
if  required.  The  use  of  the  latter  will  be  explained  below.  The  background 
is  composed  of  pure  white  standard  paper.     In  the  background  support  is 


LOVIBOND'S  TINTOMETER  289 

cut  a  shallow  groove  or  a  hole  for  the  pastille  holder,  depending  on  the 
type  used,  so  that  the  pastille  can  be  examined  without  removal  from  its 
holder.  The  tint  of  the  pastille  is  thus  compared  with  the  standard  inserted. 
It  is  possible  to  get  such  an  exact  match  in  tint  that  it  is  impossible  to  say 
on  which  side  the  pastille  was  situated.  The  advantages  of  this  radiometer 
over  others,  where  the  Sabouraud  pastille  is  employed,  are  : 

(1)  The  colour  standards  are  kept  constant  and  invariable  in  tint,  are 
easily  kept  clean,  and  do  not  fade.  The  smaller  differences  between  the 
fractional  doses  are  readily  appreciated. 

(2)  They  have  all  been  verified  experimentally  in  tinea  work,  and  any 
fractional  or  multiple  dose  can  be  standardised. 

(3)  There  is  provision  of  a  separate  series  for  daylight  and  standard 
artificial  light.  A  series  could  be  worked  out  for  any  constant  source  of 
light  if  required. 

The  standards  are  composed  of  tinted  glass  and  can  be  suppHed  for  any 
fractional  dose,  from  the  unexposed  pastille,  or  Tint  A  of  Sabouraud,  up 
to  2  B  ;  in  other  words,  the  standard  for  any  dose  up  to  10  H,  or  20  X,  can 
be  suppHed  in  an  absolutely  accurate  and  permanent  form.  It  has  been 
thought  desirable  to  retain  the  symbol  B  to  represent  the  erythema  dose, 
for  doses  in  therapeutic  work  are  usually  spoken  of  in  terms  of  "  B  "  in 
this  country. 

The  doses  in  common  use  are  those  for  : 


A 

^B 

HB 

iB 

tB 

2    B 

4B 

+  B 

But  standards  for  any  intermediate  dose  can  be  made  to  order. 

There  are  also  neutral-tint  glasses  for  use  when  measuring  the  un- 
exposed pastille  and  the  ^  and  |  B  in  daylight.  Parts  of  a  set  can  be  obtained 
if  desired. 

This  instrument  is  the  result  of  an  enquiry  into  the  colour  changes 
occurring  in  the  Sabouraud-Noire  pastille  when  exposed  to  X-rays.  The 
standards  are  invariable  and  do  not  fade.  Equal  accuracy  can  be  obtained 
by  white  daylight  or  by  electric  light.  The  standard  electric  light  is 
that  from  an  8  c.p.  carbon  filament  lamp,  with  frosted  glass  and  in  good 
condition.  Failing  a  carbon  filament  lamp,  a  low-power  metal  filament  lamp 
with  frosted  glass  may  be  used,  but  the  results  are  better  and  more  accurate 
with  the  carbon  filament  lamp  which  was  used  for  the  experimental  work. 
The  pastille  should  be  about  6  inches  away  from  the  lamp  ;  care  should  be 
taken  that  no  shadows  are  thrown  upon  it.  The  pastille  should  be  examined 
in  its  holder.  The  exact  dimensions  of  the  holder,  as  well  as  that  of  the 
pastille  in  use,  should  be  given,  or  preferably  a  specimen  submitted  to  be 
fitted  to  the  instrument.  The  area  of  pastille  exposed  to  the  action  of  the 
rays  should  be  of  such  a  size  that  on  looking  down  the  instrument  none  of  the 
unchanged  green  colour  should  be  visible.  Therefore  those  holders  that  only 
expose  half  of  the  pastille  should  not  be  used.     The  actual  aperture  which 

19 


290 


RADIATION  THERAPEUTICS 


controls  the  amount  of  pastille  exposed  to  view  can  be  varied  to  suit 
requirements. 

The  examination  should  be  made  rapidly,  as  the  pastille  fades  even  in 
electric  light. 

The  Epilation  Dose. — When  new  pastilles  are  used,  the  standard  for  1  B 
allows  a  20  per  cent  margin  of  error  on  either  side,  i.e.  -|  nearly  always  epilates 
and  11  B  is  nearly  the  absolute  limit  of  safety  for  unfiltered  rays.  For  quite 
accurate  work  new  pastilles  should  always  be  used.  The  tint  of  a  used  and 
bleached  pastille  can  always  be  compared  with  the  standard  ;  if  it  is  definitely 
more  yellow  than  this  it  should  be  discarded  in  any  case.     The  daylight 


n 

^/j 

'^^i-^^ 

'"■^  i.!^ 

"^"■^ 

jQf^^ 

X 

"~~~-^ 

^^ 

^ 

—  t 

^ 

s 

X 

J                            < 

1 

\ 

' 

°                            < 

% 

\ 

X 

o^>^ 

fj-'i 

,,  U9Kt_ 

---- 

-—-~"~ 

^ 

' 

^^^c-^ 

T       T 

^-*^'^^ 

^_2t^ 

^-^^ 

c 

.  I       I    . 

J 

i                  1 

0                        1 

1 

\                 1 

o 

3                  Z 

Time  t>«  Interruptions 


m 


mm 


Fig.  211. — Curves  showing  colour  developed  by  Sabouraud's  pastille  when  exposed 
to  unfiltered  X-rays  in  measured  doses. 


standards  for  the  unexposed  pastille  and  for  J  and  ^  B  require  the  additional 
use  of  neutral-tint  glasses  if  the  coloms  are  to  be  matched  exactly,  otherwise 
they  are  brighter  than  standard,  due  to  the  white  light  reflected.  This 
brightness  is  dulled  by  the  interposition  of  a  standard  neutral-tint  glass. 
The  grade  of  neutral-tint  varies  very  slightly  with  the  amount  of  varnish 
on  the  pastille.  On  an  average  the  neutral-tints  required  are  1-5  for 
the  unexposed  pastille,  0-4  for  |  B,  and  0-2  for  |  B.  For  higher  doses 
no  neutral  tints  are  necessary.  When  measuring  by  electric  light  a  neutral 
tint  is  only  required  for  the  unexposed  pastille  standard,  and  this  is  usually 
about  "50. 

Hampson's  RadiometeP. — This  is  a  new  radiometer  designed  for  the 
purpose  of  reducing  the  length  of  time  which  is  necessary  before  the  full  dose 
may  be  given  when  employing  the  Sabouraud-Noire  pastilles. 

It  consists  of  a  series  of  twenty-five  very  carefully  graded  tints,  which 


HAMPSON  RADIOMETER 


291 


represent  the  colour  assumed  by  a  pastille  of  barium  platino  cyanide  under 
the  action  of  X-rays. 

The  initial  or  zero  tint  is  the 
colour  of  the  unexposed  salt,  and 
the  sixteenth  change  represents  the 
brown  shade  of  colour  equivalent 
to  the  maximum  or  B  tint  of  a 
pastille  as  employed  by  Dr.  Sabou- 
raud. 

The  radiometer  consists  of  these 
tints  arranged  upon  a  circular  card, 
the  latter  being  enclosed  in  an  outer 
case.  This  has  a  small  aperture  cut 
in  it,  through  which  the  tints  can  be 
successively  viewed  one  at  a  time, 
and  the  aperture  is  so  shaped  that 
the  sensitive  pastille  can  be  placed 
in  close  proximity  to  the  tint,  the 
latter  being  rotated  by  the  thumb 
until  an  exact  match  in  colour  has 
been  obtained. 

Another  small  opening  exposes 
to  view  a  series  of  numbers,  ranging 
from  0  to  24,  whereby  the  tints  can  be  identified, 
in  black  cloth. 

Tints  are  so  arranged  that  for  exact  matching  they  shall  be  viewed 
by  artificial  light  as  obtained  from  an  ordinary  incandescent  carbon  lamp. 
In  hospital  practice  this  is  found  to  be  the  most  convenient,  as  artificial 
hght  is  frequently  employed,  and  there  is  nearly  always  a  pilot  lamp  on 
the  switchboard  by  which  the  tints  may  be  accurately  gauged. 

The  radiometer  is  so  sensitive  that  it  is  possible  to  measure  with  accuracy 
the  pastille  tint  when  it  has  not  become  nearly  such  a  dark  colour  as  in  the 
case  of  the  Sabouraud  method,  and  Dr.  Hampson  reduces  by  half  the 
exposure  time  for  an  epilation  dose,  by  bringing  his  patients  nearer  to  the 
X-ray  tube  than  was  hitherto  permissible  in  view  of  the  danger  which  might 
accrue  from  inaccurate  judgment  of  the  colours. 

When  employing  this  method  it  is  necessary  to  place  the  pastille 
on  the  patient's  skin,  and  a  full  epilation  dose  is  obtained  when 
the  pastille  has  turned  four  divisions  of  the  scale.  When  the  sensi- 
tive pastilles  are  exposed  to  daylight,  it  is  known  that  they  return 
to  a  great  extent  (although  not  absolutely)  to  their  initial  colour,  and 
this  appliance  provides  a  means  of  using  a  pastille  safely  in  this  con- 
dition, as  it  is  only  necessary  to  place  it  in  the  radiometer  before  use 
and  find  the  number  which  indicates  its  colour,  and  the  full  dose  will 
then  be  obtained  when  the  pastille  has  turned  to  another  tint  nearly  four 
stages  darker. 


Fifi.  212. — Haiiipsou  radiometer. 
(Xewton  and  W^right.) 


The  whole  is  covered 


292  RADIATION  THERAPEUTICS 

It  should  be  noted  that,  since  the  darker  shades  are  not  so  readily 
distinguishable  as  the  lighter  ones,  it  is  not  advisable  to  use  the  same  pastille 
more  than  four  times  in  succession.  Also  that  the  colour-change  of  the 
pastille  is  not  exactly  even,  the  earlier  stages  being  slower  in  proportion  to 
the  X-rays  received  ;  in  each  exposure  of  a  fresh  pastille  therefore  it  is  better 
to  stop  a  little  short  of  the  fOTir-stage  tint. 

Further,  the  delicate  gradations  of  tint  available  in  this  instrument  have 
made  manifest  the  widely  difierent  interpretations  put  by  different  observers 
on  the  same  shade  of  colour.  It  is,  therefore,  wise  for  operators  who  have  not 
worked  long  enough  with  the  new  instrument  to  be  sure  of  their  own  inter- 
pretation of  the  finer  shades,  to  stop  short  of  what  appear  to  be  the  four 
complete  grades  in  giving  the  epilation  dose. 


The  Use  of  Filters 

The  question  of  filtration  is  an  important  one,  and  a  diversity  of  opinion 
exists  as  to  the  value  of  filters.  So  important  is  this  question  that  a  great 
deal  of  discussion  has  taken  place  on  the  matter,  but  as  yet  no  standard 
filter  has  been  agreed  to.  Some  authorities  are  content  to  filter  through 
boiler  felt,  tungstate  of  calcium  on  lint,  etc.  Others  use  aluminium  or  leather. 
The  valuable  work  done  on  this  question  by  Gauss  and  Lembeke  of  Freiburg 
has  seemed  to  prove  that  aluminium,  when  properly  used,  is  undoubtedly 
the  best  of  all  the  filters.  Felt,  if  used  of  sufficient  thickness,  is  an  excellent 
filter,  and  in  the  hands  of  some  may  be  sufficient. 

The  position  of  the  filter  in  relation  to  the  patient  and  the  X-ray  tube 
is  a  point  of  the  greatest  importance.  If  it  is  close  to  the  skin  it  must  be 
earthed.  A  layer  of  some  material,  such  as  lint,  leather,  or  paper,  must  be 
placed  between  the  filter  and  the  skin  in  order  to  absorb  the  secondary 
radiations  which  are  largely  given  ofi  when  aluminium  is  struck  by  X-rays. 
It  is  a  better  plan  to  place  the  filter  at  the  half  distance  between  the  anti- 
cathode  and  the  surface  of  the  body,  and  even  at  this  distance  the  skin  should 
be  protected  by  felt  or  wash  leather.  A  number  of  filters  of  varying  thick- 
nesses should  be  provided — from  ^  mm.  to  2  or  3  mm.  form  a  good  set. 
These  are  used  according  to  the  object  aimed  at  and  the  frequency  of  the 
exposures. 

After  an  extensive  use  of  these  filters  the  opinion  has  been  arrived  at 
that  no  ill  effects  directly  attributable  to  the  secondary  radiations  from 
aluminium  have  ever  been  obtained.  Reactions  have  occurred,  but  they 
have  readily  been  traced  to  the  frequency  and  length  of  the  exposures, 
and  not  to  secondary  radiations. 

In  the  treatment  of  cancer  by  X-rays  the  writer  is  convinced  that  the 
results  obtained  when  using  aluminium  filters  have  been  better  than  when 
boiler  felt  or  other  materials  were  used.  By  gradually  increasing  the 
thickness  of  the  filter,  it  has  been  possible  to  give  larger  doses,  and  those 
more  frequently,  than  would  have  been  possible  without  their  use.     He 


THE  USE  OF  FILTERS 


293 


attributes  this  improvemeut  in  results  unreservedly  to  the  help  afforded  by 
these  filters,  and  to  the  employment  of  very  hard  tubes,  which  are  so  generally 
used  when  filters  are  employed. 

It  is  remarkable  to  note  how  often  the  same  area  may  be  treated  without 
producing  any  marked  reaction.  When  the  reaction  is  not  very  great, 
treatment  can  be  steadily  continued  with  an  increasing  thickness  of  filters, 
whereas  without  their  use  it  would  have  to  be  suspended  for  weeks  and 
valuable  time  would  be  lost. 

The  treatment  may  be  continued  even  in  the  presence  of  marked  re- 
action if  the  healthy  skin  can  be  protected  by  thick  layers  of  lead  or  lead 
rubber,  leaving  only  the  diseased  areas  exposed  to  the  treatment. 

Filter  Equivalents.— Dr.  R.  W.  A.  Salmond,  working  in  the  Research 
Laboratory  of  the  Cancer  Hospital,  conducted  an  exhaustive  investigation 
into  the  value  of  the  various  substances  used  for  filtration  of  X-rays.  His 
results  show  a  remarkable  uniformity,  and  will  be  of  the  greatest  use  to 
the  radiotherapist.     A  tabulated  list  of  his  conclusions  is  given  below  : 


Filtration  Equivalents  for  Hard  Therapeutic  X-Ray  Tubes 


Aluminium. 

Pure  Com- 
pressed Paper.i 

Tanned 
Leatlier.2 

Chamois 
Leather. 

Boiler  Felt.        ^"Ss"" 

Lead  Acetate 
Lint.4 

•5  mm. 
1 
2 
3 

3  mm. 

7     „ 
13     „ 
17     „ 

3  mm. 

7     „ 
13     „ 
16    „ 

10  mm. 
18     „ 
35     „ 
59     „ 

13  mm.             2  layers 
30     „                4      „ 
67     „                8      „ 
97     „             12      „ 

1  layer 

2  layers 
4      „ 

6      „ 

The  Selection  of  the  Filter. — This  largely  depends  upon  the  object 
of  the  treatment.  In  superficial  lesions  a  ^  mm.  filter  of  aluminium  will 
suffice.  When  treatment  has  to  be  contmued  over  a  long  period,  at  frequent 
intervals,  then  it  is  well  to  use  a  filter  1  mm.  thick  for  several  weeks,  and 
gradually  increase  up  to  3  mm.  The  choice  of  filter  in  malignant  disease  is 
fully  discussed  in  the  chapter  on  the  treatment  of  mahgnant  disease.  In  the 
treatment  of  myoma  uteri  by  the  Freiburg  technique  the  filter  is  3  mm.  thick. 
This  was  found  by  Gauss  to  be  the  most  useful  one,  and  it  afiords  ample 
protection  when  many  ports  of  entry  are  employed.  In  these  cases  great 
care  must  be  exercised  to  prevent  overlapping  of  the  areas. 

Additional  Filters. — In  addition  to  the  metal  filters,  a  number  of 
thick  felt  pads  and  a  good  supply  of  chamois  leather  will  be  found  useful, 
A  supply  of  thick  lead  sheets  should  be  at  hand.  Lead  rubber  is  also  very 
useful  for  protecting  the  skin  surrounding  the  area  to  be  treated  ;  pieces 
can  be  cut  to  the  desired  shape  and  size,  and  as  they  are  easily  sterilised 
they  may  be  used  again  for  the  same  patient. 

1  Known  as  London  board.  ^  As  used  for  repairing  boots. 

3  Average  hospital  quality  of  lint  thoroughly  soaked  in  a  saturated  solution  of  sodium 
tungstate,  and  allowed  to  dry  in  the  air. 

*  Same  similarly  treated  with  lead  acetate. 


294 


RADIATION  THERAPEUTICS 


The  Choice  of  the  X-Ray  Therapeutic  Tube 

This  is  a  most  important  matter.  A  great  variety  of  tubes  are  in  use,  and 
eacli  type  of  tube  has  its  enthusiastic  advocates.  The  earlier  therapeutic  tubes 
were  of  small  diameter,  and  were  exhausted  to  work  with  a  small  amount 

of  current  in  the  secondary, 
the  resistance  of  the  tube  being 
kept  low  in  order  to  ensure  a 
large  percentage  of  soft  rays 
discharging  from  the  tube.  The 
bulb  of  the  tube  was  made  very 
thin  with  the  intention  of 
allowing  as  many  of  the  soft 
rays  to  pass  as  possible.  Special 
glass  windows  were  introduced 
opposite  the  anti -cathode  to 
allow  still  further  the  softest 
rays  to  pass. 

A    gradual    tendency    has 
asserted  itself  of  late  to  use  the 
larger     tubes,    and    a    harder 
quality  of    ray  has  taken  the 
place  of  the  very  soft  one.    The 
latter  was  found  to  produce  a 
considerable  degree  of  reaction 
and  even  dermatitis  without  in 
any  way  increasing  the  thera- 
peutic   action    on    the   deeper 
tissues.     Even  in  the  treatment 
of  ringworm  it  has  been  found 
that    satisfactory    results     are 
obtained  when  a  hard  tube  is 
used,  and  the  reaction  obtained 
is  much  less  than 
that  from  a  soft 
tube.       And    in 
this  disease   the 


use 
filter 


of    I    mm. 


of    alu- 


FiG.  213. — Diagram  to  illustrate  a  method  of  circulating  water  to  the  anti 

cathode  of  a  tube.      (Schall. ) 

The  tube  is  shown  unprotected.    This  would  not  occur  in  actual  practice. 


mmium  gives 
quite  good  re- 
sults, with  hardly 

any  reaction,  and  only  slight  delay  in  the  epilation.  So  that  even  for 
the  most  superficial  conditions  we  may  have  to  treat,  a  hard  ray  can 
be  employed  and  a  filter  used.  The  Coohdge  tube  promises  to  be 
of  great  value  in   therapeutics.     With  its  ready  adjustment  of   quality 


THERAPEUTIC  TUBES 


295 


of  ray  emitted  from  the  tuBe  it  should  be  possible  to  select  the  proper 
degree    of    hardness   at   will,   and    arrange    the    tube     to    produce  it    for 


Fk;.  214. — Macalaster  Wiggiii  X-ray  tube. 


an  unlimited  time.  The  new  tube  makes  the  reproduction  of  precisely 
similar  rays  at  a  subsequent  exposure  possible.  Many  of  the  difficulties 
at  present  existent  in  the  control  of  X-ray  tubes  should  disappear  if  this 


Fig.  215. — Penetrans  tube.     (C.  Andrews.) 


tube  answers  to  its  expectations.    For  superficial  work,  such  as  treatment  of 
skin  diseases  and  particularly  ringworm,  a  small  tube  will  do  excellent  work. 


296  KADIATION  THERAPEUTICS 

It  must  be  kept  for  sucli  work,  and  should  never  be  allowed  to  pass  more  than 
1  milliampere  of  current.  When  carefully  used  it  is  possible  to  get  a  great 
deal  of  work  from  these  small  tubes.  For  all  deep  work,  where  great  pene- 
tration is  required,  the  larger  tubes  are  absolutely  necessary.  These  may  be 
of  any  type  so  long  as  they  meet  the  requirements  of  the  cases  treated. 
The  water-cooled  is  a  good  example  of  the  tube  suitable  for  deep  therapy. 
There  are  two  varieties  of  this  tube  : 

(1)  The  Penetrans,  a  tube  with  a  small  bulb.  Attached  to  it  is  a  larger 
accessory  bulb,  which  favours  the  maintenance  of  the  vacuum  (see  Fig.  215). 
This  tube  makes  it  possible  to  get  closer  to  the  skin  surface  with  the  anti- 
cathode.     The  tube  is  fitted  with  an  osmosis  regulator. 

(2)  The  ordinary  water-cooled  tube  is  also  very  useful.  Both  of  these 
tubes  may  be  fitted  with  a  circulating  flow  of  cold  water  by  means  of  a 
special  apparatus. 

Of  the  later  types  of  tubes  which  are  made  to  stand  heavy  currents  for 
long  periods,  the  radiator  tube  of  Cossar  or  Gundelach  and  the  Macalaster 
Wiggin  are  most  useful  (Fig.  214).      Dessaeur  (Fig.  216)  has  recently  manu- 


Air  supply 


Fig.  216. — Dessaeur  therapeutic  tube. 

factured  a  tube  which  emits  a  particularly  hard  ray,  and  which  he  claims 
to  be  approximately  as  good  as  the  Gamma-ray  of  radium.  The  tube  is 
fitted  with  a  spray  which  impinges  a  stream  of  water  vapour  upon  the  back 
of  the  anti-cathode.  If  this  tube  possesses  a  fraction  of  the  power  which  is 
claimed  for  it,  it  should  be  a  good  tube  for  deep  therapeutic  work.  But 
in  all  probability  the  Coohdge  tube  will  be  the  main  stand-by  of  the  radio- 
therapist in  the  future. 

The  routine  practice  of  the  writer  is  to  employ  large  tubes  for  practically 
all  therapeutic  purposes.  The  advantages  claimed  for  these  tubes  of  greater 
diameter  are  : 

(1)  The  tube  maintains  its  vacuum  much  longer  than  the  smaller  one, 
and  is  not  so  easily  thrown  out  of  adjustment. 


COOLING  OF  THE  X-EAY  TUBE  297 

(2)  It  may  be  used  witfr  mucli  heavier  currents  and  for  a  longer  time. 
When  thoroughly  seasoned,  a  large  tube  may  be  run  for  hours  without 
showing  any  appreciable  variation  in  hardness.  This  is  most  important 
when  large  areas  require  treatment  or  when  deep-seated  tissues  have  to  be 
radiated. 

Methods  used  for  cooling  the  X-ray  Tube. — In  view  of  the  increasing 
importance  of  X-ray  therapeutics,  and  the  increased  calls  that  are  con- 
sequently made  upon  the  X-ray  tube,  all  accessory  methods  of  regulation  and 
cooling  must  be  carefully  considered.  Of  the  cooling  devices  the  two  methods 
most  likely  to  be  employed  are  : 

(1)  The  water-cooled  tube,  with  a  constant  circulation  of  water  to  the 
anti-cathode. 

(2)  The  air-cooled  tube,  where  both  the  cathode  and  the  anti-cathode 
are  cooled  by  a  supply  of  air  obtained  from  a  motor-driven  pump. 

By  means  of  these  cooling  devices  and  the  use  of  a  rhythmic  interrupter, 
it  is  possible  to  get  therapeutic  effects  upon  deep-seated  tissues  by  means 
of  greatly  increased  dosage,  both  of  time  and  hardness  of  ray.  Five  and 
six  milliamperes  may  be  passed  through  a  hard  tube  for  a  considerable 
period. 

The  water-cooled  tube  is  the  most  useful.  With  care  in  usage,  this 
tube  will  answer  to  all  the  requirements  of  present-day  therapeutics.  It 
is  very  important  that  the  tube  should  be  gradually  seasoned  before  it  is 
subjected  to  a  severe  test.  If  this  is  done,  large  currents  may  be  passed 
through  it  for  long  periods  and  the  hardness  of  the  tube  be  maintained. 
Air-cooled  tubes  are  useful  in  places  where  a  large  amount  of  work  has  to  be 
done.  These,  again,  must  be  seasoned  before  they  are  severely  tested.  Of 
radiator  tubes,  the  Cyclops  is  one  of  the  best  for  therapeutic  work ;  it 
answers  all  the  tests  which  can  be  applied  to  it. 

Sometimes  a  new  tube  is  hopelessly  reduced  in  its  first  few  runs  with 
the  apparatus.  Such  a  tube,  if  re-exhausted,  frequently  recovers  and  works 
well  for  long  periods.  The  chief  point  to  remember  when  using  an  X-ray 
tube  is  to  work  it  carefully  up  to  its  highest  degree  of  stability,  this  being 
its  best  possible  condition  for  heavy  and  prolonged  work. 

The  appearance  presented  by  the  tube  in  action  has  been  described  in 
the  text  and  illustrated  in  the  coloured  frontispiece ;  the  pictures  shown  were 
coloured  from  tubes  made  of  glass  prepared  in  Germany.  Tubes  made  in 
England  showa  different  picture, the  colour  being  blue  instead  of  apple-green. 
The  difference  in  the  fluorescence  is  due  to  the  composition  of  the  glass.  It 
is  therefore  necessary,  when  using  tubes,  made  of  English  glass,  to  remember 
the  difference  in  the  appearance  of  the  active  tube. 


THE   TREATMENT  OF   DISEASES   OF  THE   SKIN 

No  greater  testimony  to  the  value  of  X-rays  in  the  treatment  of  diseases 
of  the  skin  could  be  given  than  the  fact  that  all  skin  hospitals  have  an  X-ray 
department,  and  that  nearly  every  specialist  includes  a  more  or  less  perfect 
installation  in  his  armamentarium. 

To  get  uniformly  good  results  the  technique  must  be  thorough,  and  the 
operator  able  to  reproduce  at  will  definite  conditions  of  the  X-ray  tube. 
Careful  data  must  be  kept  in  order  to  facilitate  the  reproduction  of  conditions 
known  to  have  been  useful  in  previous  similar  cases. 

It  may  be  laid  down  as  an  axiom  that  it  is  the  chronic  conditions  of  skin 
disease  which  receive  most  benefit  from  X-ray  treatment,  and  that  no  case 
of  acute  disease  should  be  treated  by  radiation  before  time  has  been  allowed 
for  the  inflammatory  processes  to  subside.  An  exception  may  be  made  if 
malignant  disease  is  present,  as  there  the  inflammatory  processes,  if  carefully 
helped  by  treatment,  may  lead  to  improvement. 

Further,  all  previous  treatment  must  be  considered  before  X-ray  treat- 
ment is  commenced,  and  preliminary  treatment  by  iodine,  mercurials,  and 
ointments  containing  metallic  bases  must  be  discontinued.  The  X-ray 
treatment  should  not  be  started  at  once  in  these  cases  ;  time  must  be  allowed 
for  these  substances  to  be  removed  from  the  skin.  Internal  treatment  by 
drugs  need  not  necessarily  be  discontinued,  though  if  it  is  desired  to  deter- 
mine the  value  of  X-rays  unaided  by  these  remedies  they  should  also  be  dis- 
continued. In  some  cases  the  iron  and  arsenic  of  tonics  may,  by  circulating 
in  the  blood,  aid  in  the  curative  effects  by  their  secondary  radiations.  This 
point  has  been  discussed  elsewhere. 

Subsequent  to  X-ray  treatment,  soothing  lotions  and  ointments  may  be 
employed,  but  care  must  be  exercised  in  their  selection  and  use.  In  some 
cases  the  judicious  use  of  a  stimulating  lotion  or  ointment  may  be  necessary, 
but  as  a  general  rule  all  that  is  required  is  the  dusting  of  the  part  with  a 
powder  containing  starch  and  a  little  zinc  oxide. 

All  crusts  must,  if  possible,  be  gently  removed  from  the  surface  to  be 
treated  ;  if  a  discharge  is  present  the  surface  should  be  gently  rubbed  over 
with  a  pad  of  cotton  wool.  The  exposures  necessary  are  purely  a  question  of 
experience,  and  the  degree  of  filtration  to  be  employed  is  determined  in  the 
same  way. 

The  important  point  is  to  obtain  the  maximum  of  benefit  with  the 
minimum  of  harm,  and  it  is  well  to  bear  in  mind  that  serious  harm  may 
be  done  by  the  injudicious  use  of  X-rays. 

298 


TREATMENT  OF  DI8EA8E>S  OF  THE  SKIN  299 

Eczemata.— Subacute  and  chronic  eczema  will  often  clear  up  under 
X-rays  when  all  other  methods  fail.  The  first  dose  should  be  unfiltered 
with  the  tube  fairly  soft  and  a  3-  to  4-inch  spark-gap.  A  Sabouraud  pastille 
should  be  coloured  to  the  B  tint,  its  distance  from  the  skin  being  the  half 
distance  of  the  skin  from  the  anti-cathode.  It  should  be  noted  that  derma- 
tologists who  use  X-rays  in  treatment  advise  |  PD  or  less  in  some  cases. 
These  minimum  doses  can  be  administered  at  frequent  intervals.  In  this 
connection  it  may  be  observed  that  Hampson,  Batten,  and  others  employ  the 
method  by  which  the  tube  is  brought  nearer  to  the  skin,  and  the  pastille  used 
on  the  skin  instead  of  at  the  half  distance ;  when  using  this  method  the 
dose  should  be  estimated  by  Hampson's  radiometer.  But  beginners  are 
advised  to  adhere  to  the  preceding  method.  Should  the  distance  be  greater 
than  usual  the  dose  requires  to  be  longer.  It  is  important  that  the  pastille 
should  always  be  at  the  half  distance.  Later  doses  should  be  given  through 
an  aluminium  screen  of  -5  mm.  thickness. 

This  allows  of  more  frequent  exposures,  and  also  of  a  harder  ray  being 
used  when  deeper  than  superficial  eiiects  are  necessary.  When  the  cure 
begins  to  progress  the  action  may  be  continued  by  a  dose  once  in  three 
weeks.  After  the  disease  has  disappeared  it  is  well  to  give  a  few 
exposures  at  longer  intervals  to  keep  up  the  effect  and  prevent  the 
recurrence. 

Psoriasis.— This  very  persistent  disease  will  frequently  clear  up  under 
X-ray  treatment.  The  technique  is  the  same  as  that  for  eczema,  except  that 
in  most  cases  -5  mm.  filter  may  be  used  from  commencement  of  treatment. 
The  effect  of  the  filter  appears  to  be  that  the  superficial  reaction  is  avoided, 
and  the  doses  may  be  given  more  frequently.  Large  areas  of  psoriasis  may 
be  treated  once  a  week  for  three  or  four  weeks  ;  later,  once  in  three  weeks 
is  sufficient.  A  general  efiect  as  well  as  a  local  is  often  observed,  patches 
at  a  distance  from  the  area  treated  slowly  clearing  up.  From  his  experience 
of  X-ray  treatment  of  psoriasis,  the  writer  has  arrived  at  the  conclusion  that 
cases  thoroughly  treated  by  X-rays  clear  up  fairly  rapidly,  and  do  not  show 
such  a  marked  tendency  to  recur  as  they  do  when  treated  by  other  methods. 

Prurig-O. — Some  forms  of  prurigo  benefit  by  X-ray  treatment.  The 
technique  employed  should  be  similar  to  that  for  eczema. 

Lichen.— Chronic  forms  are  likely  to  improve  under  similar  treatment. 
'  Leueoplakia.— Many  cases  of  this  disease  have  been  treated  by  X-rays. 
The  writer  is  inclined  to  favour  radium  in  these  conditions,  but  good  results 
may  be  obtained  by  X-ray  treatment.  A  filter  should  be  employed.  It  is 
well  to  remember  that  in  many  of  these  cases  there  is  a  syphilitic  taint,  and 
that  in  others  the  condition  is  complicated  by  a  cancerous  tendency.  When 
the  latter  is  present  the  case  is  likely  to  be  very  obstinate  in  its  resistance  to 
treatment.  Cases  which  show  no  evidence  of  improvement  are  probably 
cancerous.  The  employment  of  hard  tubes  and  adequate  filtration,  com- 
bined with  frequent  dosage,  may  lead  to  a  rapid  improvement  in  cases  where 
no  improvement  had  taken  place  under  the  lighter  doses. 

Trichophytia  or  Ringworm.— A  number  of  diseases  are  due  to  the 


300  RADIATION  THERAPEUTICS 

presence  in  the  horny  structure  of  the  skin  of  hypomycetes.  The  treatment, 
where  the  scalp  is  involved,  is  specially  dealt  with.  When  situated  in  other 
parts  of  the  body  characteristic  chronic  lesions  are  found.  When  situated 
in  hairy  parts  of  the  body  X-rays  are  useful.  The  action  of  the  rays  consists 
in  epilation,  and  the  removal  of  the  parasite  along  with  the  hair.  When  the 
condition  involves  the  nails  and  other  parts,  a  few  X-ray  exposures  should 
be  tried,  filtration  and  a  hard  tube  being  likely  to  prove  useful. 

The  X-ray  treatment  of  ringworm  has  been  in  general  use  since  1904. 
A  very  large  number  of  cases  have  been  treated  since  that  time,  and  it  is 
now  generally  recognised  to  be  the  most  satisfactory  treatment  yet  used  for 
this  very  intractable  disease. 

The  technique  employed  has  been  carefully  elaborated  by  Kienbock. 
Dr.  Adamson,  who  drew  attention  to  this  method  in  an  article  published  in 
the  Lancet  in  1909,  has  simplified  the  technique,  and  in  this  country  his  is 
the  one  generally  employed.  It  aims  at  the  complete  epilation  of  the  scalp 
in  all  cases  treated.  There  are  exceptions  to  this,  however.  When  the  area 
of  disease  is  localised  to  a  small  patch,  it  is  well  in  some  cases  to  treat  the 
patch,  and  trust  to  preventive  measures  so  far  as  the  rest  of  the  scalp  is 
concerned.  If  the  whole  scalp  is  shaved  at  regular  and  short  intervals 
until  all  the  affected  hairs  have  fallen  out,  the  disease  may  be  effectually 
checked.  This  is  a  good  method  to  employ  in  young  and  dehcate  children, 
or  in  subjects  who  are  suspected  of  being  very  susceptible  to  the  action  of 
X-rays.  That  such  a  susceptibility  does  exist  in  a  very  small  percentage  of 
individuals  the  writer  is  absolutely  convinced.  Every  now  and  then,  in 
spite  of  the  most  careful  technique,  a  case  is  noticed  which  gives  a  violent 
reaction  to  minimum  doses.  Permanent  alopecia  may  result  in  these  cases. 
This  exceptional  sensibility  to  rays  has  been  met  with  in  adults,  where  there 
could  have  been  no  question  of  an  overdose  of  X-rays,  yet  where  a  most 
violent  dermatitis  was  set  up  by  a  single  dose,  which  was  much  less  than 
usual,  the  pastille  being  barely  turned  to  the  half  tint,  and  the  other  factors, 
i.e.  spark-gap  constant  and  the  time  well  under  what  was  known  to  turn  a 
pastille  with  the  particular  tube.  Attention  has  been  called  lately  to  a 
variation  in  the  X-ray  tube,  which  could  not  be  recognised  by  the  ordinary 
methods,  where  the  pastille  was  changed  in  normal  time  to  the  B  tint,  but 
where,  nevertheless,  the  reaction  which  followed  was  very  great.  In  spite  of 
such  evidence  the  writer  has  not  the  shghtest  doubt  that  very  rarely  will  a 
case  of  extreme  susceptibiHty  be  met  with,  and,  so  far  as  Ave  know,  there  is  no 
method  by  which  we  can  determine  beforehand  the  existence  of  such  a  sus- 
ceptibility. Such  individuals  may  be  known  to  respond  to  other  forms  of 
skin  stimulation.  Thus  there  may  be  a  history  of  reaction  to  sunlight  or 
to  counter-irritants  or  to  antiseptic  lotions,  etc.  Cases  which  show  these 
characteristics  should  either  be  treated  with  extreme  care  or  left  alone. 

Recognising  that  such  cases  must  be  met  with  in  the  practice  of  all 
operators,  and  taking  all  possible  care  to  exclude  them  from  active  treatment, 
it  must  be  admitted  that  X-rays  are  the  best  method  we  have  for  dealing 
with  ringworm. 


TECHNIQUE  OF  RINGWORM  TREATMENT  301 

There  are  other  points  wiiich  must  be  taken  note  of  before  we  treat  a 
case  with  X-rays. 

A  careful  enquiry  must  be  made  as  to  all  previous  treatment  par- 
ticularly in  cases  of  long  standing.  Such  cases  have  been  frequently 
treated  with  counter  irritants,  as  mentioned  on  page  298.  No  patient 
should  be  treated  until  all  reaction  from  such  treatment  has  subsided. 

The  existence  of  a  septic  condition  of  the  scalp  must  be  treated  with 
caution,  otherwise  violent  dermatitis  may  result. 

It  must  be  borne  in  mind  that  the  tendency  of  the  disease,  if  of  long 
standing,  is  to  produce  a  degree  of  alopecia  which  may  be  more  or  less 
permanent.  Such  cases  will  often  give  rise  to  trouble  and  anxiety  in  the 
after  treatment. 

Children  who  possess  fair  hair  respond  more  readily  to  X-ray  treatment 
than  those  with  dark  hair,  consequently  the  dosage  must  in  the  former  case 
be  rather  less  than  in  the  latter.  Tuberculous  conditions  of  the  scalp  are 
met  with  in  children  suffering  from  ringworm.  These  local  patches  may 
be  stimulated  and  a  degree  of  dermatitis  set  up  quite  independently  of  the 
X-ray  treatment.  Such  conditions,  however,  generally  subside  and  heal 
naturally. 

The  technique  modified  by  Dr.  H.  G.  Adamson  is  so  complete  and 
practical  that  we  quote  it  as  a  guide  for  the  treatment  of  aU  cases,  with  the 
exceptions  mentioned  above  : 

Epilation  by  means  of  the  X-rays  is  now  fully  estabhshed  as  the  most 
satisfactory  method  of  treatment  for  ringworm  of  the  scalp.  By  the  introduc- 
tion of  Sabouraud's  pastilles  as  a  means  of  measurement  of  dosage,  in  trained 
hands  the  dangers  of  the  treatment  have  disappeared.  By  Sabouraud  and 
Noire's  method,  with  circular  locaHsers,  ten  to  twelve  exposures  are  necessary  in 
order  to  X-ray  the  whole  scalp,  and  reckoning  fifteen  minutes  for  each  exposure, 
the  time  occupied  in  X-raying  the  whole  scalp  is  from  3|  to  4  hours.  By  the 
method  to  be  described  the  number  of  exposm^es  necessary  to  epilate  the  whole 
scalp  is  reduced  to  five,  so  that  it  is  possible  to  irradiate  the  whole  scalp  in  IJ 
hours. 

The  essential  featm-es  are  that  no  cyfindrical  nor  lead  foil  locaHsers  are 
used,  but  that  adjacent  X-ray  applications  are  made  in  such  a  manner  that 
at  those  parts  where  overlapping  does  occur,  the  incidence  of  the  rays  is 
so  oblique,  and  so  much  further  from  the  source,  that  no  excessive  dose  is 
given. 

'  I  have  used  this  5-exposure  method  with  perfect  results,  eVery  part  of  the 
scalp  has  received  an  even  radiation,  and  the  hair  has  fallen  out  completely, 
without  any  sign  of  overlapping  margins  or  areas  with  non-faUen  hairs  as  evidence 
of  insufiicient  exposure.  There  is  no  sign  of  erythema  ;  the  regrowth  of  the  hair 
has  been  normal  over  the  whole  scalp. 

The  details  of  the  method,  as  Dr.  Adamson  employed  it,  are  as 
follows  : 

1.  The  hair  is  clipped  short  over  the  whole  head  to  facilitate  operations. 

2.  Five  points  are  marked  out  on  the  scalp  with  a  blue  skin  pencil,  as  follows 
(see  Figs.  217,  218)  : 


302 


RADIATION  THERAPEUTICS 


In  the 
middle  line. 


At  the  sides 
of  the  scalp. 


'  Point  A^  1|  to  2  inches  behind  the  frontal  margin  of  the  hairy 

scalp. 
Point  B,  1  to  1|  inches  above  the  centre  of  the  flat  area  which 

forms  the  upper  part  of  the  occiput. 
Point  C,  just  above  the  lower  border  of  the  scalp  at  the  lower 
part  of  the  occiput. 
(  Point  D,  on  the  left  side^  just  above  and  in  front  of  the  ear. 
{  Point  E,  on  the  right  side,  just  above  and  in  front  of  the  ear. 
Measured  with  a  tape  measure,  the  distance  between  any  two  of  the  five 
points  should  be  exactly  5  inches. 

3.  The  five  points  are  joined  up  by  lines  made  with  a  skin  pencil.     These  lines 
should  meet  one  another  at  right 
angles.    The  mapping  out  of  these 
points  and  lines  need  not  occupy 
more  than  one  or  two  minutes. 


Fig.   217. — Diagram  illustrating  Dr. 
Adamson's  method.      (Schall. ) 


Fig.  218. — Diagram  showing  centres  of  areas  to  be  rayed. 
(Schall.) 


4.  A  Sabouraud  pastille  dose,  with  the  anticathode  at  6|  inches  from  the 
nearest  point  of  the  scalp,  is  given  to  the  vertex,  occiput,  lower  occiput,  right 
side,  and  left  side  in  succession,  taking  the  points  A,  B,  C,  D,  and  E  as  the  centre 
of  each  area  to  be  rayed,  and  placing  the  tube  so  that  the  line  joining  the  anti- 
cathode  and  the  nearest  part  on  the  scalp  is  at  right  angles  to  a  similar  line 
joining  the  anticathode  with  each  of  the  central  points  of  the  adjacent  areas. 
The  lines  which  have  been  drawn  on  the  scalp  connecting  the  five  points  give 
an  indication  of  the  direction  in  which  the  dose  is  to  be  aimed,  i.e.  of  the  position 
of  the  tube  in  relation  to  the  head.  The  applications  to  the  vertex,  upper 
occiput,  and  the  two  sides  are  best  made  with  the  patient  lying  on  a  couch. 
The  forehead  and  eyes  must  be  shielded  by  a  piece  of  lead  or  protective  rubber 
during  the  exposure  to  the  front  of  the  vertex,  and  the  ears  and  sides  of  the 
face  when  the  sides  of  the  head  are  exposed.  The  fifth  application,  that  to  the 
lower  occiput,  is  best  given  with  the  patient  sitting  down  and  resting  the  fore- 
head on  a  low  table.     A  shield  must  be  used  to  protect  the  neck. 

In  order  to  ensure  fixing  the  anticathode  at  the  correct  distance  from  the 
scalp  during  the  exposure,  three  slender  wooden  pegs  are  fitted  to  the  box  which 
encloses  the  tube.  The  pegs  converge  at  their  extremities  to  within  ^  inch  of 
each  other,  and  are  of  such  a  length  that  the  part  of  the  scalp  which  rests 
against  them  is  just  6|-  inches  from  the  anticathode  of  the  tube.     The  pegs 


TREATMENT  OF  RINGWORM  303 

are  made  of  soft  wood,  so  as  not  to  obstruct  the  passage  of  the  rays 
through  tliem.  The  pegs  rest  against  the  sralp  just  over  the  blue  marks  A,  B, 
C,  D,  and  E,  according  to  the  area  to  be  rayed.  The  aperture  in  the  box  through 
which  the  rays  pass  is  3  inches  in  diameter  and  3^  inches  from  the  anticathode, 
so  that  at  the  level  of  the  points  of  the  pegs  the  rays  diverge  to  a  circle  of  6 
inches  diameter,  and  in  this  way  one  avoids  the  escape  of  rays  into  the  room  or 
towards  the  operator  or  on  to  the  patient's  shoulders,  for  a  circle  of  this  diameter 
is  blocked  by  the  patient's  head.  At  the  same  time  this  circle  of  irradiation  allows 
a  sufficient  margin  for  the  necessary  overlapping  of  the  doses. 

The  essential  points  in  this  method  are  to  direct  each  irradiation  at  right 
angles  to  the  direction  of  the  irradiation  of  adjacent  areas,  and  to  aim,  not  at  a 
point  in  the  centre  of  the  vertex,  of  the  lower  occiput,  or  of  the  sides  of  the 
scalp,  but  towards  the  outer  margin  of  these  areas,  so  that  half  the  dose  goes 
on  to  the  scalp  and  half  on  to  the  shield  protecting  the  face  and  neck.  If  these 
precautions  be  taken  there  is  no  risk  of  over-exposure  at  the  overlapping  margins 
of  the  rayed  areas.  In  practice  the  dosage  works  out  so  nicely  that  every  part 
receives  an  equal  amount,  and  epilation  is  total  and  complete,  without  any- 
where a  sign  of  over-  or  under-exposure.  In  theory,  according  to  the  well- 
known  laws  that  the  quantity  of  rays  received  at  any  point  exposed  varies  (1) 
inversely  with  the  square  of  the  distance  from  the  source  ;  and  (2)  directly 
with  the  size  of  the  angle  of  incidence,  the  dose  received  by  any  part  of  the  scalp 
is  found  to  be,  with  mathematical  accuracy,  one  pastille  dose. 

In  a  case  which  has  received  a  sufficient  irradiation  the  hair  begins  to 
fall  out  about  the  fourteenth  day,  and  epilation  should  be  complete  in  from 
three  to  four  weeks,  a  shght  general  erythema  of  the  scalp,  which  soon  sub- 
sides, being  frequently  noticed. 

The  regrowth  of  the  hair  is  a  matter  of  time,  and  varies  in  different 
subjects.  It  commences  soon  after  the  hair  has  fallen,  and  may  be  seen  in 
the  form  of  a  fine  down  all  over  the  scalp,  the  complete  regrowth  being 
generally  well  under  way  in  three  months  from  the  time  of  treatment. 

The  variations  may,  however,  be  very  great,  e.g.  the  growth  may  be 
unequal,  this  depending  upon  the  vitality  of  the  hair  follicles.  The  previous 
treatment  may  have  devitahsed  the  follicles  to  a  more  or  less  marked  degree. 

Careful  attention  must  be  paid  to  the  foUowing  points  ia  all  cases  : 

(1)  The  scalp  must  be  shaved  before  the  treatment  is  undertaken.  This 
enables  the  extent  of  the  mischief  to  be  determined,  and  facihtates  the 
marking  of  the  scalp.  It  also  allows  the  rays  to  penetrate  freely,  thick  hair 
acting  as  a  filter,  and  preventing  the  thorough  treatment. 

(2)  The  scalp  must  be  kept  clean  after  the  exposures  ;  the  head  should 
be  washed  with  soap  and  warm  water  two  or  three  times  a  week.  Until 
all  the  hair  has  fallen  out  the  case  is  still  infectious ;  it  is,  therefore,  well 
to  use  a  simple  ointment,  such  as  boracic  acid  (weak),  or  even  vaseline, 
to  prevent  the  spores  from  spreading,  and  possibly  infecting  other  children. 
A  skull  cap  of  Hnen  is  useful  for  this  purpose  and  also  serves  to  keep  the 
head  warm.     In  some  cases  stronger  antiseptic  ointments  may  be  used. 

Folliculitis  Barbae. — Satisfactory  results  maybe  expected  if  the  proper 
technique  is  carried  out.  Care  must  be  taken  to  regulate  the  dose,  so  that 
no  permanent  damage  to  the  hair  folHcles  results.     It  must  be  insisted  upon 


304  RADIATION  THERAPEUTICS 

that  no  active  local  treatment  be  carried  on  simultaneously  with  the 
X-ray  treatment.  A  full  erythema  dose  should  be  given  unfiltered,  and 
three  weeks  allowed  to  elapse  before  a  repetition  is  given.  The  affected 
hairs  fall  out,  and  the  condition  rapidly  improves.  Subsequent  treatments 
should  be  given  at  three  or  four  weeks'  intervals.  Generally  one  thorough 
dose  is  sufficient  to  cure  the  condition. 

Lupus  Vulg'aris. — This  condition  readily  responds  to  X-ray  treatment. 
Sometimes  in  remote  situations  of  the  body  it  will  be  necessary  to  resort  to 
radium  because  of  the  greater  facihty  this  remedy  offers  in  application. 
When  the  disease  is  situated  on  an  accessible  part  of  the  body,  X-rays  should 
be  the  remedy  employed. 

Finsen  light  has  been  extensively  used  for  the  treatment  of  lupus,  but 
X-rays  will  do  all  that  the  light  can  do,  and  they  are  more  easily  employed. 
The  treatment  is  much  shorter,  and  not  nearly  so  tedious,  and  the  results 
are  obtained  in  shorter  time  and  are  quite  as  good  and  lasting.  Several  cases 
which  did  not  respond  to  Finsen  light  treatment  have  cleared  up  after  a 
short  course  of  X-rays.  To  select  the  proper  degree  of  hardness  of  the  ray 
is  the  essential  point,  and  filters  should  be  used.  After  the  lesion  has  healed, 
several  thorough  doses  should  be  given  at  intervals  of  several  weeks,  and 
the  patient  should  be  kept  under  observation  for  a  considerable  length  of 
time  in  order  that  any  recurrence  may  be  detected  at  the  earliest  possible 
date,  and  promptly  treated.  The  results  obtained  by  X-ray  treatment  are 
excellent,  and  the  degree  of  reparative  change  which  the  tissues  show  is 
often  remarkable. 

Lupus  Erythematosus  is  another  condition  which  responds  to  ray 
treatment.  It  is,  however,  a  very  chronic  condition,  and  tends  to  spread 
after  treatment  has  ceased.  The  occurrence  of  telangiectasis  is  not  un- 
common after  prolonged  X-ray  treatment  in  a  percentage  of  cases  treated. 

Acne  Vulg'aris. — When  widely  spread  this  condition  is  difficult  to 
treat,  but  several  exposures  given  at  intervals,  covering  the  whole  of  the 
affected  area,  will  tend  to  a  considerable  improvement  in  the  condition. 
The  technique  is  similar  to  that  for  eczema. 

Verrucae  Vulg'ari  or  Warts. — This  condition  is  particularly  amen- 
able to  X-rays,  but  there  are  other  remedies  which  are  quite  as  efficacious. 
Carbonic  acid  snow  and  radium  act  well.  Two  or  three  exposures  to  X-rays 
lead  to  a  rapid  disappearance  of  the  warts. 

Cheloid. — This  condition  is  rapidly  and  permanently  influenced  by 
X-ray  treatment.  As  it  occurs  so  frequently  after  operations  for  cancer  and 
other  conditions,  the  radiotherapist  has  many  opportunities  of  observing 
its  progress  after  treatment.  The  transformation  of  a  thick  fleshy  cheloid 
condition  into  a  soft  flexible  scar  is  one  of  the  most  remarkable  instances 
of  the  reparative  change  which  can  be  induced  by  ray  therapeutics.  The 
relief  obtained  is  also  great,  the  scar  becoming  flexible,  and  the  movements 
of  the  limb  rapidly  improving  The  treatment  requires  to  be  thorough,  and 
the  whole  of  the  cheloid  must  be  treated  equally  and  regularly.  A  full 
pastifle  dose  may  be  given  without  a  filter,  and  at  the  end  of  fourteen  days  a 


TREATMENT  OF  HYPERIDR08LS  305 

second  dose,  with  -5  mm.  of  aluminium  as  a  filter,  will  induce  the  necessary 
degree  of  reaction.  This  must  be  kept  up  by  subsequent  doses  at  regular 
intervals,  until  the  whole  scar  approximates  to  the  normal.  The  results 
obtained  in  extensive  cheloid  after  burns  are  highly  satisfactory,  the  irrita- 
tion which  is  so  common  a  symptom  in  these  cases  being  quickly  relieved, 
often  permanently.  A  soft  pliable  scar  takes  the  place  of  the  thickened  and 
unsightly  one  found  before  treatment. 

Chronic  Syphilitic  Lesions  of  the  Skin  are  often  sent  for  X-ray 
treatment,  either  with  or  without  an  established  diagnosis.  When  very 
obstinate,  a  few  X-ray  exposures  will  serve  to  stimulate  the  tissue  changes 
and  tend  to  improvement,  especially  if  antisyphilitic  remedies  are  employed 
at  the  same  time.  It  should  be  noted  that  these  cases  frequently  respond 
actively  to  minimum  doses,  so  care  must  be  taken  not  to  push  the  treatment 
too  far  or  too  rapidly.  Time  must  be  allowed  to  observe  how  the  condition 
is  likely  to  react  before  further  doses  are  administered. 

Simple  Ulcers. — These  readily  respond  to  X-ray  treatment.  Un- 
healthy sores  will  assume  under  treatment  a  healthy  granulating  appearance, 
and  in  time  will  heal  completely.  The  resulting  cicatrix  is  generally  a 
■good  one,  and  will  in  all  probability  give  no  further  trouble. 

Fissures  in  the  skin  and  mucous  membrane  and  fissured  ulcers  of  the 
tongue  are  frequently  greatly  improved  by  adequate  treatment. 

Chronic  Ulcers  which  fail  to  improve  under  other  remedies  will  show 
a  marked  improvement  when  treated  by  a  few  pastille  doses  ;  where  granula- 
tions are  present,  but  flabby,  the  stimulating  effect  of  the  rays  greatly  helps 
to  an  improvement  in  the  general  condition  of  the  ulcer.  Many  cases  heal 
slowly  with  prolonged  treatment. 

Malig-nant  Invasions  of  the  Skin  will  be  dealt  with  in  the  section  on 
the  Treatment  of  Malignant  Diseases. 

Hyperidrosis. — Excessive  sweating  in  various  situations  of  the  body  is 
a  condition  which  up  to  the  time  of  treatment  by  X-rays  was  the  despair  of 
the  skin  specialist.  Whatever  its  situation,  it  is  a  most  unpleasant  condition 
to  deal  with,  and  a  source  of  great  annoyance  to  the  patient.  The  common 
situations  are  the  axillae,  the  hands,  the  feet,  and  the  head.  Wherever  it 
occurs,  it  may  be  readily  and  permanently  cured  by  X-ray  treatment. 
Howard  Pirie  drew  attention  to  this  method  of  treatment,  and  published  a 
number  of  cases  which  demonstrated  the  great  value  of  X-rays  in  this  dis- 
ease. No  more  striking  testimony  to  the  efficacy  of  X-rays  in  therapeutics 
could  be  obtained  than  the  results  of  treatment  of  this  condition. 

The  writer  has  treated  a  number  of  cases  with  invariably  excellent 
results.  The  marked  improvement  in  the  condition  after  a  few  exposures 
is  very  gratifying. 

Technique  in  the  Axillce. — The  arm  is  extended  and  placed  over  the  head, 
the  axilla  being  fully  exposed.  A  circular  aperture  is  made  in  a  piece  of 
lead  rubber  protective,  and  then  a  piece  of  lint  is  laid  over  the  axilla,  exposing 
the  whole  of  the  apex  and  the  axillary  hair.  The  tube-box  with  the  tripod 
already  described  is  brought  close  down  to  the  skin,  the  apex  of  the  tripod 

20 


306 


RADIATION  THERAPEUTICS 


being  on  a  level  with  the  apex  of  the  axilla.  A  full  pastille  dose  is  given,  and 
at  the  end  of  fourteen  days  another  exposure  is  given,  a  -5  mm.  filter  being 
employed  for  this  and  subsequent  exposures.  No  improvement  is  noticed 
until  after  the  second  or  third  administration,  when  a  slight  reddening  of  the 


Fig.  219. 


-Chronic  ulcer  of  hand  of  several  years'  duration,  showing  improvemeut  under 
X-ray  treatment. 


skin  results,  there  being  also  slight  irritation  at  this  stage.  The  sweating 
slowly  diminishes  from  this  stage  until  a  complete  cure  is  obtained,  four 
applications  being  usually  sufficient  to  cure  the  condition.  It  is  better  to 
obtain  the  result  gradually  by  the  above  method,  though  occasionally,  when 
the  dose  has  been  heavier,  a  marked  improvement  may  follow  the  first 
exposure.  It  is  also  well  to  aim  at  a  partial  effect  only  ;  a  slight  degree  of 
sweating  is  practically  a  normal  condition,  and  is  what  should  be  attained. 
If  the  sweating  is  completely  stopped,  a  dry  condition  of  the  skin  may  follow, 


THE  TREATMENT  OF  ENLARGED  LYMPHATIC  GLANDS  307 

which  may  be  troublesome.  .  It  is  frequently  noticed  that  the  axillary  hair 
is  not  completely  epilated,  which  rather  suggests  that  less  than  a  full  ery- 
thema dose  is  sufficient  to  destroy  a  large  percentage  of  the  sweat  glands. 
The  hands  and  feet  may  be  treated  in  exactly  the  same  way.  The  head 
requires  to  be  dealt  with  carefully,  otherwise  a  troublesome  alopecia  may 
result. 


THE   TREATMENT   OF   ENLARGED   LYMPHATIC 

GLANDS 

Enlargred.  Glands  may  be  described  as  (a)  simple  inflammatory ; 
(b)  tuberculous  ;  (c)  lymphadenomatous  ;  (d)  lympho-sarcomatous  ;  (e) 
carcinomatous  ;  the  two  latter  being  generally  secondary  to  a  lesion  else- 
where. 

Inflammatory  Glands  which  come  for  treatment  are  generally  chronic  ; 
they  readily  respond  to  the  X-ray,  and  diminish  rapidly  in  size. 

As  these  glands  are  frequently  secondary  to  septic  conditions  elsewhere, 
a  search  should  be  made  for  the  primary  lesion,  and  this  should  be  treated 
as  well  as  the  glands.  If  treated  early,  before  suppuration  has  occurred, 
these  glands  will  sometimes  subside.  If  suppuration  is  present,  the  abscess 
should  be  opened,  and  afterwards  a  number  of  X-ray  exposures  will  greatly 
facilitate  the  repair  of  the  parts.  This  is  particularly  appreciable  where  an 
intractable  sinus  exists.  It  may  be  injected  with  bismuth  emulsion,  and  a 
thorough  irradiation  given. 

The  treatment  of  Tuberculous  Glands  by  X-rays  offers  a  good  alterna- 
tive to  that  of  removal  by  operation,  and  when  operation  is  recommended  a 
few  preliminary  exposures  should  be  given  in  order  to  induce  inflammatory 
changes  around  the  glands. 

Glands,  which  on  account  of  the  extensive  nature  of  the  condition 
renders  operation  a  serious  matter,  either  because  of  the  wide  distribution 
of  the  swelling,  or  on  account  of  suppuration  already  well  advanced,  may 
be  treated  vigorously  by  weekly  doses.  In  the  absence  of  more  operative 
treatment  suppuration  should  not  be  a  contra-indication  to  X-ray  treatment; 
such  treatment  should  rather  be  pushed  vigorously.  When  pus  has  formed 
it  should  be  evacuated  and  the  treatment  continued.  It  is  remarkable  how 
some  of  the  cases  improve  from  the  commencement  of  X-ray  treatment. 
The  action  is  undoubtedly  a  general  and  local  one,  the  former  appearing  to 
exert  a  tonic  effect  upon  the  tissue  metabolism. 

Lymphadenomatous  Glands  are  frequently  treated  by  X-rays,  and 
l)ehave  in  much  the  same  manner  as  tuberculous  glands,  sometimes  disappear- 
ing rapidly  or  diminishing  to  a  very  small  size.  Their  peculiar  characteristic 
is  that  they  tend  to  reappear,  or  rather,  a  group  of  glands  will  diminish  in 
size,  and  after  treatment  is  discontinued  for  a  time  the  lumps  become 
evident  again,  but  whether  they  are  the  same  glands  or  others  which  have 
become  involved  is  a  matter  of  conjecture.     The  practical  point  is  that  this 


308  EADIATION  THEEAPEUTICS 

type  of  gland  is  particularly  amenable  to  X-ray  treatment,  but  tbe  treatment 
cannot  be  definitely  described  as  a  curative  one  untU  months  or  years  bave 
elapsed  without  recurrence.  The  experience  of  most  workers  is  that  ulti- 
mately recurrence  takes  place,  and  the  patient  dies  from  the  disease.  The 
probability  is  that  a  percentage  of  the  cases  which  are  cured  may  have  been 
of  the  simple  inflammatory  type. 

The  treatment  must  be  thorough  ;  areas  in  which  glands  are  evident 
should  be  treated.  It  is  a  good  plan  to  treat  all  the  areas  involved  in  rota- 
tion, taking  care  to  cover  as  wide  an  area  as  possible  at  each  treatment. 
In  this  way  it  is  possible  to  secure  a  rapid  response  to  treatment.  The 
irradiation  should  be  continued  long  after  the  patient  appears  to  have 
recovered.  It  is  possible  that  in  a  number  of  the  cases  where  there  has  been 
recurrence,  efficient  after-treatment  has  not  been  carried  out.  A  dose  once 
a  month  for  many  months  will  not  harm  the  patient,  and  it  may  possibly 
keep  up  the  beneficial  action  of  radiations. 

Eecently,  by  using  hard  rays  and  aluminium  filters,  1  mm.  to  2  mm. 
thick,  it  has  been  possible  to  give  more  frequent  doses,  and  a  marked  improve- 
ment in  results  has  been  obtained. 

Enlarged  Sarcomatous  Glands  may  be  a  manifestation  of  lympho- 
sarcoma or  secondary  to  a  primary  sarcoma  in  an  adjacent  part  of  the  body. 
In  the  former,  the  treatment  of  the  local  condition  must  be  pursued  as  well 
as  of  the  deposits  in  the  mediastinum.  Frequent  dosage  with  hard  rays  is 
indicated.  The  glands  slowly  diminish  in  size,  but  never  quite  return  to 
the  normal  condition  ;  sooner  or  later  the  glandular  enlargement  increases, 
and  in  spite  of  treatment  the  patient  succumbs  to  the  disease. 

Secondary  deposits  of  sarcoma  in  the  glands  yield  to  treatment  for  a 
time.  Several  cases  which  have  been  treated  by  X-rays  and  radium  have 
remained  well  for  several  years.  The  latter  agent  appears  to  have  a  decidedly 
beneficial  action  upon  sarcoma. 

Enlarged  Carcinomatous  Glands  are  generally  secondary  to  a 
primary  lesion  in  another  part  of  the  body,  and  may  occur  in  any  part  of 
the  lymphatic  system.  The  primary  lesion  will  be  found  in  some  adjacent  part 
or  organ.  They  differ  from  the  preceding  types  of  gland  by  slow  growth, 
are  generally  not  numerous,  and  may  be  confined  to  one  particular  chain  of 
lymphatic  distribution,  corresponding  to  the  site  of  the  primary  lesion.  They 
do  not  tend  to  suppurate.  The  skin  may  at  a  later  stage  become  involved, 
and  ulceration  follow.  The  response  to  treatment  is  slow,  marked  inflam- 
matory surface  reaction  being  often  necessary  before  an  appreciable  effect 
is  noticed  upon  the  size  of  the  glands.  In  these  cases  it  must  be  recognised 
that  if  benefit  is  to  be  received  the  possibility  of  damage  to  the  skin  must 
be  partially  disregarded,  though  all  precautions  must  be  taken  to  avoid  it  or 
reduce  it  to  a  minimum. 

But  several  cases  have  remained  stationary  until  a  degree  of  ulceration 
of  the  skin  surface  has  been  brought  about.  This  will  gradually  heal,  and 
at  the  same  time  the  glands  slowly  subside.  They  seldom  disappear  entirely, 
but  appear  to  become  quiescent.     In  several  patients,  where  such  a  change 


PLATE  LIX. — Rodent  Ulcers  treated  with  Radium,  X-Rats,  and  CO.,. 

a,  Rodent  ulcers  on  left  side  of  face  ;  these  rapidly  healed  after  radium  exposures  and  remained  healed. 
6,  Small  rodent  ulcer  of  right  side  of  nose,  healed  all  but  a  small  area  at  the  lower  edge  of  the  ulcer  ;  this 
has  been  most  intractable  to  X-rays,  radium,  and  COg. 


KODENT  ULCER  309 

has  been  induced,  it  has  been  possible  to  remove  the  glands  surgically,  and 
continue  the  X-ray  treatment  afterwards. 

The  condition  of  a  patient  so  treated  is  infinitely  better  than  when  the 
glands  are  allowed  to  enlarge  slowly,  involve  the  skin,  and  ulcerate.  Once 
a  carcinomatous  gland  arrives  at  the  stage  where  it  breaks  down  all  barriers 
and  reaches  the  surface,  no  amount  of  X-ray  or  other  treatment  has  any 
effect.  The  technique  is  somewhat  similar  to  that  for  tuberculous  glands. 
Weekly  doses  with  filtered  rays  may  be  employed,  taking  care  to  cover  a  wide 
area,  and  changing  the  area  as  frequently  as  possible.  In  advanced  cases, 
with  groups  of  greatly  enlarged  glands,  it  will  be  necessary  to  administer 
heavy  doses  rapidly.  This  may  be  safely  done  when  the  rays  are  filtered 
through  three  or  more  millimetres  of  aluminium.  Doses  of  20  or  30  X 
Kienbock  may  be  given  to  numerous  small  areas  of  skin  covering  the  en- 
larged glands.  In  this  way  large  aggregate  doses  of  200  to  400  X  may  be 
given  to  a  group  of  glands  at  one  sitting.  After  a  suitable  interval,  depending 
upon  the  degree  of  reaction  and  the  urgency  of  the  symptoms,  the  dose  may 
be  repeated. 


THE  TREATMENT  OF  RODENT  ULCERS 

The  treatment  of  rodent  ulcer  by  X-rays  has  yielded  many  good  results. 
When  the  disease  is  superficial  a  marked  improvement  is  quickly  obtained. 
The  tendency  in  all  cases  is  for  recurrence  to  show  itself,  and  adequate  steps 
must  be  taken  to  endeavour  to  prevent  this  recurrence.  This  can  best  be 
done  by  thorough  prophylactic  treatment  after  the  ulcer  has  disappeared, 
though  even  then  disappointment  will  occasionally  be  met  with.  In  some 
cases,  in  spite  of  most  thorough  prophylactic  treatment,  the  scar  breaks 
down  and  the  resulting  ulcer  spreads. 

When  bone  or  cartilage  becomes  involved  the  di£B.culty  of  healing  the 
condition  is, great.  Sometimes  the  ulcer  heals  and  remains  well  for  long 
periods.  This  indicates  that  in  the  particular  case  adequate  treatment  has 
been  carried  out.  The  exact  rationale  of  the  treatment  is  somewhat  difficult 
to  follow.     Why  some  cases  do  well  and  others  do  not  is  not  yet  understood. 

Two  cases  may  be  quoted  to  illustrate  this  point. 

Rodent  Ulcer  on  Left  Side  of  Face. — Mrs.  E.^  57  years  of  age.  From  December 
1908  to  March  1910  she  received  about  fifty  radiations.  The  condition  gradually 
improved^  but  as  soon  as  treatment  was  stopped  the  growth  resumed  an  active 
form.  On  March  11,  1910,  she  had  a  short  exposure  with  radium.  The  part 
treated  improved  greatly  for  a  time.  The  ulcer  was  ultimately  excised.  This 
is  a  type  of  slow-growing  rodent  ulcer  which  does  not  respond  readily  to  any  form 
of  treatment. 

A  Small  Rodent  Ulcer  on  the  Right  Side  of  the  Face  in  line  with  the  Orhit. — 
R.M.,  41  years  of  age.  The  growth  had  been  noticed  for  twelve  months  prior  to 
treatment.  It  had  been  cauterised  on  three  occasions  without  any  apparent 
benefit.     From  September  to  December,  1909,  sixteen  radiations.     The  surface 


310  RADIATION  THERAPEUTICS 

healed  over  and  had  a  depressed  appearance  in  the  centre  of  the  cicatrix.  The 
edges  remained  smooth.  It  remained  well  until  April  1910^  when  the  anterior 
edge  resumed  activity ^  and  slowly  spread.  Several  radiations  resulted  in  a  cure 
for  a  time  at  least.  The  last  treatment  given  resulted  in  a  fairly  active  derma- 
titis, which  seemed  to  have  the  effect  of  healing  the  active  portion  of  the  growth. 
This  case  responded  remarkably  well  to  X-rays,  and  affords  a  great  contrast  to 
the  preceding  one.  It  illustrates  the  point  that  the  earlier  these  ulcers  are  sub- 
jected to  X-ray  treatment,  the  better  is  the  prospect  of  a  cure. 

Very  superficial  iilcers  heal  readily  and  remain  healed  for  long  periods. 
The  position  of  the  ulcer  appears  to  determine  the  result  in  some  cases  ; 
when  situated  on  the  cheek,  away  from  the  orbit  and  clear  of  mucous 
membrane,  the  ulcer  will  readily  yield  to  treatment ;  when  situated  near 
an  angle  at  the  junction  of  skin  and  mucous  membrane,  such  as  the  angle  of 
the  mouth  or  orbit,  the  difficulty  of  equal  and  adequate  treatment  becomes 
greater.  It  is  often  impossible  to  get  the  rays  equally  spread  over  the  whole 
of  the  ulcer,  and  if  there  is  inequality  of  the  surface  the  same  appears  to 
apply.  It  is  also  possible  that  many  of  the  cases  which  do  not  heal  under 
treatment  have  been  treated  with  the  wrong  quality  of  ray.  We  must 
remember  that  the  X-ray  beam  is  heterogenous.  Consisting  as  it  does 
of  a  bundle  of  rays  of  unequal  penetration,  the  beam  from  any  given  tube 
may  contain  rays  in  the  discharge  of  from,  say,  1  to  12  Bauer.  The  pre- 
ponderance of  value  4  may  be  sufficient  for  the  stimulation  of  the  tissues 
of  a  particular  ulcer  while  it  would  have  no  effect  upon  another.  It  appears 
reasonable  to  assume  that  in  some  instances  we  accidentally  use  the  ray  of 
the  greatest  value  for  the  case  under  treatment,  while  on  another  occasion, 
using  the  same  tube  in  the  same  condition  on  another  case,  the  result  will 
be  quite  different.  It  would  appear  that  up  to  the  present  the  bulk  of  the 
therapeutic  work  done  with  X-rays  has  been  more  or  less  haphazard.  This 
no  doubt  explains  the  varied  results  obtained.  An  effort  must  be  constantly 
made  by  each  operator  to  standardise  his  apparatus  in  such  a  way  that  he 
may  be  able  to  produce  at  a  given  time,  approximately  at  least,  a  particular 
quality  of  ray  for  a  special  purpose. 

The  frequency  of  the  applications  must  also  have  a  direct  influence  on 
the  result,  some  operators  preferring  to  wait  three  or  four  weeks  before 
repeating  an  exposure,  while  others  do  so  at  the  end  of  a  week.  The  obvious 
course  to  pursue  is  to  observe  carefully  the  condition  requiring  the  treat- 
ment. If  the  ulcer  is  growing  rapidly  extreme  measures  must  be  adopted. 
The  dose  should  be  the  maximum  possible  and  should  be  repeated  at  the 
earliest  convenient  date.  The  edges  of  the  ulcer  may  be  given  an  excessive 
dose  by  protecting  the  less  active  part  with  lead  rubber ;  the  healthy  skin, 
all  but  that  close  to  the  edge  of  the  growth,  must  also  be  guarded.  The 
degree  of  reaction  induced  will  depend  upon  several  factors,  (a)  the  duration 
of  the  exposure,  (6)  the  hardness  of  the  X-ray  bulb,  (c)  the  filtration  employed ; 
each  of  these  factors  must  receive  special  consideration. 

In  superficial  conditions  the  first  dose  should  be  given  unfiltered,  and 
a  full  pastille  dose  given.     If  possible,  it  is  well  to  wait  for  fourteen  days 


PLATE  LX. — Cases  of  Rodent  Ulcers  Treated  with  Radium. 

a,  b,  Illustrates  a  case  which  has  resisted  all  forms  of  treatment,  including  X-rays,  radium,  COo,  and 
mercury  vajjour  lamp  ;  several  intensive  doses  of  X-rays  appeared  to  induce  healing  of  the  ulcer  for  a  time. 
Recurrence  took  place  at  the  lower  edge,  this  ra^jidly  extended  until  the  lower  half  became  ulcerated. 

c,  d,  A  case  which  yielded  to  treatment,  c,  Before  treatment,  d,  Towards  the  end  of  treatment  the 
ulcer  completely  healed  ;  recurrence  after  many  months  quickly  responded  to  further  treatment.  The  patient 
has  had  several  recurrences,  each  of  which  quickly  heals  after  radium  has  been  applied. 


RODENT  ULCER  311 

before  repeating  the  exposure.  This  allows  the  operator  to  determine  the 
degree  of  reaction  the  tissues  possess.  If,  however,  the  growth  threatens 
to  spread  more  rapidly,  a  further  exposure  must  be  given  at  once,  and  this 
one  should  be  filtered.  It  is  well  to  bear  in  mind  that  it  is  possible  to 
stimulate  a  growth  by  X-rays  and  to  get  a  harmful  rather  than  a  beneficial 
influence  exerted  upon  it. 

If,  in  spite  of  ordinary  full  doses  of  X-rays,  the  ulcer  goes  on  steadily 
increasing,  what  more  can  be  done  ?  The  obvious  course  is  to  increase 
the  dosage  further.  In  special  cases  where  time  appears  to  be  of  value  two 
or  more  pastille  doses  may  be  given  at  once,  the  healthy  parts  being  well 
guarded.  The  case  illustrated  shows  the  value  of  this  method  (Plate  LX., 
Fig.  a).  A  rodent  ulcer  on  the  right  side  of  the  forehead  resisted  all  forms  of 
treatment  by  X-ray,  radium,  carbonic  acid,  and  high  frequency.  It  gradually 
extended,  especially  at  its  lower  border.  Two  unfiltered  doses  were  given, 
and  at  the  end  of  a  week  two  more  were  administered,  treatment  being  then 
suspended  for  several  weeks.  The  ulcer  healed  over  the  whole  of  its  surface, 
a  thick  crust  forming  at  the  lower  angle.  The  patient  imagined  he  was  cured 
and  did  not  return  for  more  than  three  months ;  at  that  time  the  crust  formed 
at  the  lower  edge  of  the  ulcer  had  led  to  ulceration  below  its  surface,  which 
was  slowly  spreading.  Further  treatment  led  to  a  marked  improvement  in 
the  condition,  but  completely  failed  to  heal  the  ulcer. 

After  an  ulcer  has  been  healed  it  is  necessary  to  continue  treatment. 
Repeated  doses  may  be  administered  at  intervals  of  several  weeks,  filters 
being  employed  and  a  harder  tube  used.  By  these  means  it  may  be  hoped 
to  obtain  an  efiect  upon  the  deeper  structures  which  may  contain  renmants 
of  growth.  The  fibrosis  induced  by  treatment  should  arrest  the  growth 
of  these  remnants. 

In  obstinate  cases  it  is  wise  to  vary  the  remedy  employed.  Thus 
radium  may  be  used  or  carbon  dioxide  apphed  to  parts  of  the  ulcer.  The 
high-frequency  current  will  sometimes  give  the  necessary  stimulus  to  parts 
of  the  ulcer.  A  preHminary  exposure  to  the  mercury  vapour  fight,  followed 
by  X-ray  dosage,  sometimes  aids  the  process  of  healing.  The  fight  appears 
to  increase  the  superficial  circulation,  by  congesting  the  parts  ;  the  secondary 
radiations  may  be  induced  by  the  direct  action  of  the  X-rays  on  the  fluids 
circulating  in  the  vessels  of  the  growth. 

■  The  distinction  drawn  between  rodent  ulcer  and  epithefioma  is  more 
or  less  an  arbitrary  one,  many  of  the  ulcers  which  we  call  rodents  reaUy 
being  from  the  beginning  epitheliomata,  this  difierence,  no  doubt,  in  part 
accounting  for  the  wide  variations  in  the  result  of  treatment,  the  epithefio- 
mata  being  more  resistant  to  treatment  by  radiations.  The  latter  growths 
tend  to  spread  to  the  deeper  parts  and  involve  the  tissues  below  the  skin. 
When  cartilage  and  bone  become  affected  the  difficulty  in  inducing  heafing 
is  greater.  Much  more  penetrating  rays  should  be  employed,  and  longer 
and  more  frequent  exposures  given.  In  some  cases  it  is  well  to  combme 
surgical  measures  with  the  X-ray  treatment.  When  possible,  the  more 
or  less  complete   eradication  of   the  ulcer,  followed  by  thorough  X-ray 


312  RADIATION  THERAPEUTICS 

treatment,    appears    to    be    the    most    rational    method    that    can    be 
employed. 

The  Treatment  of  Epitheliomata 

These  tumours,  when  seen  early,  and  more  especially  when  they  involve 
mucous  membrane,  should  be  promptly  excised.  After-treatment  by  X-rays 
should  be  employed,  and  should  cover  a  wide  area  to  include  the  lymphatic 
distribution  of  the  affected  part.  Should  the  patient  refuse  operation, 
radium  should  be  the  next  choice,  and  faihng  the  possibiUty  of  treating  by 
this  remedy,  X-rays  should  be  used,  or  radium  and  X-rays  together  or 
alternately.  It  is  important  to  keep  the  patient  under  observation  for  a 
lengthy  period. 

Epithelioma  involving  the  skin  only  is  more  amenable  to  X-rays  and 
radium.  A  few  exposures  should  be  given  previous  to  operation,  if  this 
be  decided  upon,  and  continued  after  the  removal  of  the  active  growth. 


THE  TREATMENT  OF  SARCOMATA 

Sarcomata,  other  than  glandular,  may  require  to  be  treated.  Such, 
particularly  the  round-celled  variety,  when  situated  in  the  soft  parts  of  a 
limb  or  in  bone,  respond  readily  to  treatment,  and  diminish  in  size  or  may 
to  all  outward  observation  disappear.  The  tendency  is  for  recurrence 
within  a  year  or  so,  and  often  in  the  deeper  structures,  particularly  in  the 
mediastinum  or  lungs.  The  after-history  of  these  cases  is  very  little,  if  any, 
worse  than  in  the  operative  cases,  where  recurrence  is  almost  certain  to  take 
place  within  two  years. 

The  advantage  of  the  operative  method  over  treatment  by  radiations 
is  that  the  patient  is  saved  from  the  local  discomfort  of  a  growth  which 
in  the  end  breaks  down  and  forms  a  sloughing  ulcerated  sore.  Two  cases 
may  be  quoted  to  illustrate  this  point,  one  that  of  a  girl  who  had  a  primary 
sarcoma  of  the  humerus  which  practically  cleared  up  under  X-ray  treatment. 
Recurrence  took  place  in  the  left  hip-joint,  but  before  the  patient  died  the 
primary  tumour  reasserted  itself  and  formed  a  large  sloughing  sore. 

In  the  second  case  a  primary  sarcoma  of  the  right  humerus  was  removed 
by  operation,  together  with  the  shoulder  girdle  and  upper  limb.  Recurrence 
took  place  after  two  years  in  the  mediastinum  and  lungs. 


THE  TREATMENT  OF  CARCINOMATA 

The  majority  of  the  cases  of  malignant  disease  treated  by  X-rays 
belong  to  this  group.  Marked  improvements  have  taken  place  in  results 
in  recent  years.  This  has  been  largely  due  to  two  factors  :  (a)  a  better 
technique,  and  (6)  the  earlier  treatment  of  many  of  the  patients. 

The  improvement  in  X-ray  technique  has  been  very  great  of  late  years, 
the  use  of  larger  tubes  of  great  penetrative  power,  together  with  an  improve- 


THE  TREATMENT  OF  CARCINOMATA  313 

ment  in  the  construction  of  "coils,  transformers,  and  accessory  apparatus, 
having  made  it  possible  to  greatly  increase  the  dose  given.  The  use  of 
filters  of  a  thickness  of  -|  to  3  mm.  of  aluminium,  or  its  equivalent  in  other 
materials,  led  to  the  use  of  a  penetrating  ray  which  could  be  used  to  give 
large  doses  with  practically  no  effect  upon  the  skin  surface.  These  large 
doses  have  been  extensively  used  in  the  treatment  of  carcinoma,  with  very 
marked  improvement  in  the  results  obtained.  The  beneficial  effects  of 
X-rays  upon  uterine  myomata  encouraged  workers  to  try  similar  methods 
in  the  treatment  of  all  kinds  of  carcinoma,  both  superficial  and  deep.  If 
the  skin  surface  is  divided  up  into  small  areas,  the  dosage  in  a  particular 
case  may  be  increased  to  a  marked  extent ;  1000  X  Kienbock  may  be 
administered  in  a  short  time  to  a  tumour.  In  deep-seated  carcinoma  of 
the  uterus  the  treatment  employed  should  be  administered  by  two  routes — 
the  perineal  and  the  abdominal. 

The  methods  of  treatment  may  be  divided  for  practical  purposes  into 
four  main  groups  : 

(a)  Prophylactic,  before  and  after  operation  ; 

(6)  Curative  efforts  in  primary  growths,  which  should  consist  of  thorough 
irradiation  of  the  gro^wth,  enlarged  glands  and  the  adjacent  lymphatic  area  ; 

(c)  Treatment  of  recurrences  of  all  degree  ; 

(d)  Palliative  treatment  of  cases  where  all  hope  of  cure  has  gone. 
These  groups  require  lengthy  discussion. 

Before  Operation. — In  all  cases  where  time  permits  a  number  of 
X-ray  exposures  should  be  given.  The  first  exposure  may  be  given  un- 
filtered  and  later  ones  should  be  passed  through  -5  mm.  of  aluminium. 

There  should  be  no  delay  in  performing  the  operation,  but,  usually, 
a  few  days  elapse  between  diagnosis  and  operation,  and  during  these  one 
dose  at  least  may  be  administered.  The  whole  area  of  the  growth  should 
be  well  irradiated  and  then  the  area  of  lymphatic  distribution  spreading 
from  the  growth  should  be  fully  exposed.  Thus  in  carcinoma  of  the  breast 
the  whole  breast  may  be  treated  with  one  dose,  or,  if  the  tumour  is  large, 
the  breast  may  be  divided  into  four  areas  and  four  exposures  given.  This 
method  will  be  described  later.  The  axilla  should  get  a  full  dose.  This 
exposure  will  have  the  efiect  of  epilating  the  axillary  hair  and  will  exert 
an  action  upon  the  sweat  glands,  causing  a  diminution  of  the  secretion  of 
sweat,  an  effect  advantageous  in  keeping  the  axilla  clean  after  the  operation. 
When  time  permits  a  second  filtered  dose  may  be  given  over  the  whole  of 
the  areas  previously  treated. 

Post-Operative  Treatment. — In  cases  which  have  had  the  preliminary 
exposures  this  should  be  continued  as  soon  after  operation  as  possible.  In 
cases  which  have  not  had  the  preliminary  treatment,  the  same  routine  should 
be  employed.     The  following  description  therefore  applies  to  both  cases. 

As  soon  as  possible  after  the  operation  the  patient  should  be  irradiated 
over  the  whole  of  the  areas  already  described.  It  is  of  extreme  importance 
that  a  thorough  routine  method  should  be  employed.  The  difiiculty  hes 
in  the  fact  that  unless  great  care  is  exercised  to  irradiate  the  whole  area 


314  KADIATION  THEEAPEUTICS 

equally,  portions  of  the  surface  may  not  get  a  full  dose.  In  the  experience 
of  the  writer  recurrence  has  taken  place  in  areas  which  have  escaped  treat- 
ment. An  attempt  must  be  made  to  elaborate  a  technique  which  will  give 
an  equally  distributed  dose  all  over  the  breast  area,  axilla,  supra-clavicular 
region,  and  well  down  below  the  costal  margin.  A  method  similar  to 
that  used  in  the  treatment  of  the  scalp  for  ringworm  might  be  employed. 
The  whole  of  the  area  to  be  treated  should  be  mapped  out  and  central 
points  selected  which  will  get  the  maximum  dose.  Spreading  from  these 
points  to  the  periphery  of  the  area  the  rays  diminish  in  a  definite  pro- 
portion. The  peripheral  areas  of  each  exposure  should  overlap  so  that  that 
part  of  the  skin  receives  a  half  dose  from  each  adjoining  exposure. 

Points  should  be  selected  at  equal  distances  in  the  mid-mammary 
line,  extending  from  the  costal  margin  to  the  clavicle  and  upwards,  to  take 
in  the  supra-clavicular  region.  A  number  of  corresponding  points  should 
be  marked  out  in  the  mid-axillary  line,  and,  each  point  being  taken  as  the 
centre  of  the  exposure,  it  is  possible  to  give  an  equally  distributed  dose  over 
the  whole  area.  The  axilla  should  in  addition  have  a  dose  from  its  posterior 
aspect. 

The  first  series  of  doses  may  be  given  unfiltered.  At  the  end  of  a  week  a 
second  dose  is  given,  using  a  -5  mm.  aluminium  filter.  Later  doses  should 
be  administered  according  to  the  degree  of  reaction  which  results.  In  all, 
twelve  exposures  to  the  whole  area  should  be  given,  the  later  irradiations 
being  given  at  longer  intervals.  Towards  the  end  of  the  series  the  interval 
should  be  about  three  weeks,  and  for  the  later  doses  thicker  filters  and  hard 
tubes  should  be  employed. 

At  the  end  of  the  dozen  exposures  the  patient  should  be  allowed  to 
cease  coming  for  treatment,  but  should  be  kept  under  observation  for 
several  months  in  order  that  the  earliest  appearance  of  recurrence  may  be 
promptly  dealt  with. 

A  useful  routine  for  the  use  of  filters  is  to  give  the  first  dose  unfiltered, 
the  second,  third,  and  fourth  with  -5  mm.  filter,  and  then  to  proceed  to 
1  mm.  for  three  or  four  doses,  and  2  mm.  for  the  later  exposures,  the  object 
of  the  filter  being  to  protect  the  skin  as  much  as  possible,  and  to  exercise 
an  action  on  the  deeper  structures  by  penetrating  to  the  deeper  layers  of 
the  sldn  and  the  deep  tissues. 

The  results  of  prophylactic  treatment  by  X-rays  are  encouraging.  The 
effect  is  marked  from  the  first.  The  patient  has  less  pain,  the  movements  of 
the  parts  are  facilitated,  and  the  scars  are  more  pliable  at  an  earlier  date  than 
when  no  treatment  is  carried  out.  The  general  tonic  action  of  X-rays  upon 
the  metabolic  processes  is  noticed,  patients  feel  well  and  the  general  health  is 
improved  by  the  treatment.  That  recurrence  may  be  prevented  is  fairly 
well  established,  especially  in  view  of  what  we  know  to  occur  when  early 
recurrences  are  treated.  These  undoubtedly  disappear  after  treatment, 
and  it  is  logical  to  assume  that  remnants  of  cancer  left  in  the  wound  may 
disappear  in  the  reparative  changes  set  up  in  the  surrounding  tissues  by 
X-ray  treatment  when  the  treatment  has  been  efficiently  carried  out. 


"^-^^ 


PLATE  LXI. — Caecixomata  treated  by  X-bats. 

a.  Primary  growth,  a  large  ulcerated  carcinoma  of  right  breast  wliich  iniijroved  after  being  treated  by  a 
prolonged  series  of  X-ray  exijosures. 

h,  Kecurrent  growth  in  scar  after  operation  for  removal  of  carcinoma  of  right  breast.  Successful  treat- 
ment by  X-rays. 

This  is  one  of  the  very  early  cases  treated  at  the  Cancer  Hospital,  when  small  unmeasured  doses  were 
given  at  frequent  intervals  over  a  long  period  of  time. 


INOPERABLE  CARCINOMA  315 

Treatment  of  Inoperable  Carcinoma. — The  technique  in  the  treat- 
ment of  primary  grovvtlis,  unsuitable  for  operation,  being  similar,  the  descrip- 
tion under  (a)  applies  to  both  groups.  A  classification  is  necessary  in  order 
to  describe  fully  the  methods  employed. 

(a)  Large  inoperable  cancer  of  the  breast  without  ulceration  is  fairly 
common.  An  attempt  should  be  made  to  reduce  the  tumour  by  treatment 
to  an  operable  condition.  When  the  breast  is  very  large  a  system  of  treat- 
ment may  be  used  which  will  give  the  dosage  on  a  limited  area.  The  breast  is 
divided  into  four  or  more  areas  by  means  of  a  lead-rubber  screen  marked  out 
as  follows  :  A  square  of  thin  material  is  cut  to  cover  the  whole  breast  and  a 
margin  of  tissue  beyond;  this  is  divided  into  four  equal  parts,  and  one  segment 
is  cut  out.  Two  points  are  marked  on  the  skin  at  the  upper  aspect,  and 
the  upper  limits  of  the  screen  are  placed  on  these  points.  An  exposure  is 
given  through  the  segment  which  has  been  removed.  The  screen  is  then 
moved  round  one  segment  and  the  exposure  repeated.  This  is  done  until 
the  four  areas  have  been  treated,  the  tube  in  each  instance  being  directed 
towards  the  centre  of  the  breast.  This  method  has  been  successful  in  several 
cases,  the  tumour  rapidly  diminishing  in  size. 

The  gratifying  results  obtained  in  the  treatment  of  uterine  fibromyomata 
by  the  intensive  method  of  dosage  have  led  to  marked  improvements  in  the 
technique  of  the  treatment  of  carcinomata.  A  filter  of  3  mm.  is  used,  a 
secondary  filter  consisting  of  two  or  more  layers  of  loofah  sponge  enclosed  in 
several  layers  of  lint  being  used  to  protect  the  skin.  The  area  to  be  treated 
is  marked  out  into  a  number  of  small  squares.  Lead  is  used  to  protect  the 
adjacent  areas  during  the  exposure.  As  many  as  twenty  areas  may  be 
mapped  out  to  cover  the  region  requiring  treatment,  each  area  receiving  from 
10  to  20  X  on  the  Kienbock  scale.  In  this  way  a  relatively  large  dose  is 
administered  to  the  afiected  area.  The  tube  used  is  of  the  hardest  possible 
penetration,  10-12  Wehnelt.  The  patient  should  be  kept  at  rest  for  a  day 
or  two  after  the  administration  of  the  rays.  The  dosage  may  be  repeated  in 
from  two  to  three  weeks,  or  at  shorter  intervals  if  there  are  no  untoward 
symptoms  shown.  These  large  doses  of  X-rays  appear  to  exercise  a  marked 
influence  over  the  diseased  tissues.  Continental  workers  claim  marked 
improvement  in  cases  treated  by  the  intensive  method.  It  is  possible  that 
mth  further  improvement  in  X-ray  tubes,  the  results  produced  may  be 
still  greater. 

Exposures  through  thick  filters  may  be  given  twice  a  week  in  serious 
cases.  Several  layers  of  chamois  leather  should  be  laid  upon  the  skin  in 
order  to  prevent  secondary  radiations  damaging  the  skin. 

(6)  Ulcerated  growths  should  be  treated  by  a  modified  method.  An  ulcer- 
ated surface  will  stand  more  treatment  than  the  unbroken  skin,  and  there 
is  no  need  to  attempt  to  protect  it.  The  healthy  skin  around  the  ulcerated 
surfaces,  all  but  a  narrow  margin  surrounding  the  ulcer,  should  be  protected. 

Frequent  irradiations  are  given  to  this  area  until  it  shows  signs  of 
breaking  down.  In  the  end  the  cancer  mass  sloughs  and  leaves  healthy 
tissue  behind,  this  closing  up  and  occasionally  healing. 


316  KADIATION  THERAPEUTICS 

The  illustrations  shown  are  from  two  cases  treated  in  this  manner. 
Figs,  a,  b,  c,  and  d  in  Plate  LXII.  are  from  a  case  treated  on  the  lines 
indicated  above.  They  show  the  progressive  changes  induced,  viz.  sloughing 
and  gradual  repair  of  the  resulting  ulcer.  At  one  stage  this  tumour  received 
radium  treatment. 

Fig.  a  in  Plate  LXI.  is  from  another  case  which  is  showing  marked 
improvement  under  X-ray  treatment  of  the  intensive  type. 

The  treatment  of  recurrent  cancer  when  the  growth  has  reached  a  large 
size  may  be  carried  out  on  precisely  the  same  lines  as  that  for  primary 
cancer.  Many  cases  could  be  quoted  where  undoubted  benefit  has  resulted 
from  thorough  X-ray  treatment. 

(c)  Recurrent  Cancer. — These  cases  form  a  large  percentage  of  the 
patients  one  is  called  upon  to  treat.  The  condition  varies  from  the 
melon-seed  variety  to  large  nodules  of  cancer.  All  cases  do  not  respond 
equally  to  treatment,  a  number  going  steadily  from  bad  to  worse.  As  a 
general  rule,  the  instances  which  occur  in  young  women  under  35  years  of 
age  do  not  respond  well  to  treatment ;  after  that  age,  if  treated  early,  the 
chance  of  a  good  result  is  much  greater. 

In  this  class  of  case  the  treatment  should  be  pushed  vigorously  until 
a  marked  reaction  is  obtained  all  over  the  affected  surface  and  well  beyond 
it.  When  the  reaction  shows  itself  the  seed-like  bodies  slowly  subside. 
Repeated  crops  may  require  to  be  treated  in  the  same  patient.  Several 
cases  of  this  type  have  been  undergoing  X-ray  treatment  for  two  or  three 
years  at  regular  intervals. 

THE  TREATMENT  OF  ENLARGEMENT  OF  THE 
PROSTATE  GLAND 

Of  late  years  this  condition  has  been  treated  by  X-rays  and  radium. 
The  enlargement,  if  simple,  is  an  hyperplasia  of  the  glandular  elements, 
a  condition  which  should  be  amenable  to  therapeutics.  It  must  not  be 
overlooked,  however,  that  in  some  of  these  cases  there  is  a  large  fibrous 
element  in  the  growth,  and  this  may  be  fairly  dense  in  structure.  Further, 
these  conditions  may  be  complicated  by  the  presence  of  stones  or  calcified 
matter  in  the  substance  of  the  gland.  The  presence  of  a  commencing  new 
growth  has  also  been  shown  in  what  was  otherwise  to  all  appearances  a 
simple  enlargement  of  the  gland.  Cases  for  X-ray  treatment  must  therefore 
be  carefully  selected  in  order  to  avoid  bringing  discredit  upon  the  method 
of  treatment.  No  doubt  can  exist  as  to  the  brilliant  results  obtained  in 
this  condition  by  operative  measures,  and  the  writer  is  convinced  that 
X-ray  or  any  other  palliative  form  of  treatment  will  never  take  the  place 
of  early  operation. 

With  the  reservation  indicated,  good  results  have  been  obtained 
by  both  X-rays  and  radium.  It  is  a  matter  of  general  observation  that 
when  so  treated  the  condition  of  patients  is  ameliorated,  the  control  of 
micturition  is  re-established  in  some  cases,  and  prolonged  treatment  results 


PLATE  LXIL— Stages  in  the  Treatment  of  an  Atrophic  Scirrhous  Cancer  of  the  Breast. 

a,  Before   treatment.      6,  Growth    commencing  to    ulcerate,     c,  Growth  nearly  all   gone.      d,  Healed. 
Recurrence  took  place  at  the  lower  end  of  the  scar,  and  the  patient  is  still  nnder  treatment. 


EXOPHTHALMIC  GOITRE  317 

in  a  marked  diminution  in  the.  size  of  the  gland.  Large  prostates  may  by 
this  line  of  treatment  be  reduced  to  an  operable  size.  Even  in  the  cases 
which  are  operable,  circumstances  may  exist  which  indicate  a  palliative  line 
of  treatment  rather  than  the  radical  one  of  removal.  The  patient  may 
refuse  to  take  the  risk  of  an  operation,  or  his  condition  may  be  such  that  an 
operation  would  be  extremely  hazardous. 

The  technique  is  similar  to  that  for  other  deeply-seated  structures  ; 
two  routes  are  available,  both  of  which  may  be  employed  in  the  one  case. 
The  perineal  route  is  preferable.  Hard  tubes  should  be  employed  and 
filters  used  from  the  commencement  of  treatment.  It  is  important  to  prevent 
dermatitis  as  long  as  possible  in  order  to  get  a  sufficient  dosage  into  the  deep 
structures. 

Commencing  with  a  2  mm.  filter,  a  pastille  dose  at  the  half  distance 
may  be  given  weekly.  The  pastiUe  is  used  on  the  distal  side  of  the  filter, 
and  the  patient,  therefore,  receives  a  full  dose  at  each  sitting.  After  three 
or  four  doses  with  this  thickness  of  filter  it  will  be  found  necessary  to  increase 
the  thickness  to  3  mm.  and  later  to  4  or  more. 

The  skin  must  be  carefully  watched  for  reaction.  Should  this  be 
excessive  the  treatment  must  be  suspended  for  a  time  by  that  route,  and 
the  suprapubic  route  may  then  be  utilised.  A  compressor  should  be 
employed  and  the  tube  brought  well  down  towards  the  pubis,  a 
cyhnder  compressor  being  a  good  one  to  use.  The  gland  can  thus  be 
irradiated  from  above  for  several  doses,  and  then  the  perineal  route  can  be 
tried  again.  In  this  way  it  is  possible  to  keep  on  with  treatment  for  a 
considerable  length  of  time.  Improvements  generally  begin  to  show  after 
three  or  four  doses,  and  as  a  result  of  the  increase  of  comfort  the  general 
health  of  the  patient  improves  greatly. 

An  alternative  method  of  treatment,  and  one  likely  to  take  its  place, 
is  the  following  :  a  large  amount  of  current,  4  to  5  miUiamperes,  is  passed 
through  a  hard  tube,  10  Bauer,  a  3  mm.  aluminium  filter  being  employed, 
and  the  dose  measured  by  Eaenbock  paper.  At  least  10  X  on  the  skin  surface 
is  given,  the  perineal  and  suprapubic  routes  being  employed  with  as  many 
ports  of  entry  as  possible,  so  as  to  get  in  the  maximum  dose  to  the  gland. 

THE  TREATMENT  OF  EXOPHTHALMIC  GOITRE 

The  routine  medical  treatment  by  drugs  has  proved  to  be  merely 
palliative,  and  operative  treatment  has  not  been  marked  by  any  striking 
successes.  X-rays  appear  to  offer  a  chance  of  better  results  than  either 
of  the  two  older  methods.  The  rationale  of  the  treatment  by  X-rays  is 
difficult  to  understand.  A  purely  local  effect  can  easily  be  produced,  but 
there  must  be  a  deeper  and  further-reaching  influence  induced  by  the  ray  to 
explain  the  undoubted  improvement  which  takes  place  in  these  cases.  In 
a  disease  which,  grave  in  itself,  is  frequently  accompanied  by  other  conditions, 
such  as  rheumatoid  changes  in  the  joints  and  conditions  associated  with 
rheumatism,  it  is  unwise  to  claim  too  much  for  X-ray  treatment,  yet  in 


318  RADIATION  THERAPEUTICS 

suitably  selected  cases  good  results  may  be  confidently  expected.  The 
technique  employed  must  be  thorough.  The  gland  when  greatly  enlarged 
offers  a  good  field  for  the  preliminary  exposures,  which  should  be  given  once 
a  week  and  continued  steadily  until  marked  improvement  results.  Should 
reaction  lead  to  a  suspension  of  the  local  treatment,  the  radiations  may  be 
continued  on  the  surrounding  areas,  particularly  on  the  region  of  the  cervical 
sympathetic.  The  action  is  apparently  a  general  one  rather  than  a  local, 
and  therefore  the  area  of  exposure  need  not  be  limited.  An  occasional 
dose  may  be  applied  to  each  axilla  alternately. 

Does  treatment  by  radiations  lead  to  changes  in  the  gland  secretion 
or  in  the  blood  serum,  thus  producing  an  amelioration  of  the  distressing 
symptoms,  or  does  the  treatment  restore  the  function  of  the  gland  to  a 
normal  condition  ?  Whatever  happens  there  is  no  doubt  that  many  of 
the  cases  treated  by  X-rays  are  restored  to  a  normal  state  of  health. 

The  aim  of  treatment  should  be  to  slowly  induce  a  return  to  the  normal, 
consequently  it  will  be  found  advantageous  to  proceed  slowly  with  the  treat- 
ment ;  in  cases  which  are  not  very  acute  a  dose  once  a  week  to  one  side  of 
the  neck  will  suffice.  Alternate  doses  should  be  given  to  either  side  of  the 
neck.  It  will  be  an  advantage  to  employ  filters,  commencing  at  1  mm.  thick 
and  increasing  as  the  occasion  indicates.  Should  the  symptoms  be  very  acute 
the  dosage  may  be  increased  both  in  frequency  and  strength.  A  hard  ray  is 
employed,  and  this  should  be  filtered  through  3  mm.  of  aluminium.  Three 
areas  may  be  marked  out  over  the  enlarged  gland,  and  each  is  given  10  X 
Kienbock.  This  may  be  followed  in  a  week  or  ten  days  by  another  applica- 
tion. In  more  severe  cases,  which  are  confined  to  bed,  it  is  a  good  plan  to 
use  radium  rather  than  X-rays, 

From  experience  of  X-ray  treatment  in  other  diseases  it  would  appear 
that,  in  order  to  maintain  the  improvement,  it  will  be  necessary  to  give 
regular  doses  of  X-rays  at  intervals  for  a  long  period  of  time.  Dr.  Florence 
Stoney  in  an  interesting  paper  quotes  results  which  are  encouraging.  She 
advocates  X-ray  treatment  in  preference  to  operation.  In  47  cases,  7  gave 
up  treatment  too  soon,  14  were  completely  cured,  and  22  derived  great 
benefit.  Under  treatment  which  is  pushed  to  the  point  of  dermatitis,  the 
pulse  comes  down  to  normal,  the  goitre  in  many  cases,  and  the  exophthalmos 
nearly  always,  disappearing.  Tremor  and  perspiration  are  slow  to  yield 
but  do  so  eventually. 

The  writer  is  strongly  of  opinion  that  this  form  of  treatment  should 
have  a  trial  in  all  cases,  even  when  operation  is  contemplated. 

THE   TREATMENT  OF  UTERINE   FIBROMATA 

The  value  of  radio -therapeutic  measures  in  diseased  conditions  is  clearly 
demonstrated  by  the  success  which  has  been  achieved  in  the  treatment  of 
uterine  fibroids.  These  conditions  would  appear  to  offer  an  ideal  field  for 
the  action  of  radiations,  as  from  our  knowledge  of  their  action  on  superficial 
structures  we  find  that  haemorrhage  may  be  checked  and  fibrous  and  cellular 


UTERINE  FIBROMATA  310 

structures  readily  reduced  in,  size.  The  difficulty  up  to  recent  times  has 
been  to  act  on  deep-seated  structures  in  such  a  way  that  reduction  in  size 
of  tumoui's  may  be  induced  without  causing  permanent  damage  to  the  skin 
which  has  to  be  traversed  by  the  rays  before  the  underlying  organs  can  be 
reached.  The  credit  of  having  successfully  worked  out  a  technique  which 
enables  us  to  attain  that  end  is  wholly  due  to  continental  operators.  Albers 
Schonberg,  Haenisch,  Bordier,  the  members  of  the  Freiburg  school,  and 
others  have  elaborated  techniques  which  may  be  safely  ased. 

Whichever  method  we  employ,  and  this  point  is  so  important  that  the 
principal  of  these  will  be  described  in  detail,  it  is  essential  that  the  work 
should  be  done  by  a  skilled  radiologist  in  conjunction  with  a  gynaecologist, 
and  not  entrusted  to  inexperienced  workers.  Routine  detail  work  must 
be  done  in  every  case  if  success  is  to  be  attained.  All  cases  must  not  be 
treated  indiscriminately,  but  a  careful  selection  should  always  be  the  rule. 

Indications  for  Treatment  in  Fibroma  Uteri. — The  indications 
for  radio-therapeutic  treatment  depend  upon  the  following  factors  : 

(1)  Age  of  the  Patient. — All  authorities  agree  that  patients  under  40 
years  of  age  should  not  be  treated  by  X-rays,  because  before  that  age  the 
treatment  for  obtaining  an  artificial  menopause  would  be  too  long  and  tedious. 
Other  factors  to  be  considered  at  that  age  are  obvious.  The  upward  age- 
limit  is  difficult  to  fix.  The  patient  should  be  of  such  an  age  that  her  monthly 
periods  still  persist,  or  at  all  events  these  should  not  have  ceased  longer  than 
a  year.  It  is  therefore  between  the  ages  of  40  and  52,  or  at  most  55,  that 
radio-therapeutic  measures  are  indicated,  though  it  must  be  noted  that 
patients  beyond  this  limit  have  been  successfully  treated. 

(2)  Nature  of  the  Fibroma. — The  interstitial  form  is  the  one  most 
amenable  to  radio-therapeutic  treatment,  the  pediculated  or  sub-peritoneal 
variety  being  better  treated  by  operation. 

(3)  HcBmorrhage. — According  to  Bordier  the  most  suitable  are  the 
fibromata  with  marked  hsemorrhage,  i.e.  cases  where  the  periods  have  been 
very  copious,  with  abundant  clots,  or  replaced  by  veritable  haemorrhage. 
As  a  rule  after  the  second  cycle  of  irradiation,  the  discharges  have  completely 
and  permanently  disappeared. 

(4)  Size  of  the  Fibroma. — Fibroma  of  moderate  volume  are  more  easily 
influenced  than  those  of  larger  size,  but  larger  tumours,  reaching  even  to 
the  umbilicus,  may  be  considerably  reduced  in  size.  Very  large  tumours 
are,  however,  better  suited  for  operation. 

(5)  Hcemorrhage  at  Menopause  with  or  without  fibroids  is  easily  cured 
or  relieved  by  radio-therapy. 

Contra  Indications.^ — ^Bordier  is  of  opinion  that  radio-therapeutic 
treatment  is  not  applicable  : 

(1)  When  the  fibroma  is  calcified  or  presents  necrobiotic  degeneration. 

(2)  When  myomata  are  malignant,  infected,  or  gangrenous. 

(3)  When  complications  exist  such  as  suppurating  salpingitis  or  pelvic 
peritonitis. 

He  also  quotes  the  following  results  : 


320  EADIATION  THERAPEUTICS 

After  the  second  or  third  cycle  of  irradiation  the  fibromatous  patient 
entirely  loses  all  discharge,  the  hsemorrhage  as  well  as  any  colourless  dis- 
charge from  which  she  may  have  suffered.  In  the  same  time  the  volume 
of  the  fibroma  will  have  begun  to  be  reduced  as  early  as  the  commencement 
of  the  second  cycle.  This  diminution  of  volume  steadily  continues,  and 
after  the  third  and  fourth  cycle  it  is  often  found  that  the  uterus  has  regained 
its  normal  size.  It  is  not  at  all  rare  to  see  a  fibromatous  uterus,  of  the  size 
of  a  fist,  atrophy  after  three  or  four  cycles  of  irradiation  to  such  an  extent 
that  it  can  no  longer  be  palpated  through  the  abdominal  wall. 

A  large  number  of  cases  have  been  treated  on  the  Continent  and  in 
America,  and  a  more  limited  number  have  received  treatment  in  this  country. 
From  a  consideration  of  the  results  it  would  appear  that  a  large  percentage 
of  cases  received  marked  benefit,  symptoms  being  relieved,  and  in  many 
cases  the  tumour  was  so  reduced  that  the  uterus  appeared  to  return  nearly 
to  the  normal.  How  lasting  the  benefit  may  be  has  yet  to  be  determined. 
At  present  the  patient  may  be  assured  that  she  will  receive  no  damage  of 
the  skin,  at  all  events  of  a  serious  nature.  Superficial  reaction  may 
occur  in  spite  of  all  the  care  that  may  be  taken.  When  using  the  large  doses 
of  the  Freiburg  school,  it  is  possible  that  deep-seated  changes  may  be  induced 
over  which  we  can  have  no  control.  Care  must  therefore  be  exercised  not 
only  in  the  choice  of  case  for  treatment  but  in  the  choice  of  technique  we 
employ.  It  is  well  for  the  operator  to  master  thoroughly  one  technique  and 
confine  his  attention  to  it. 

Technique  for  Uterine  Myomata  and  Climacteric  Troubles  {Albers 
Schdnberg). — (1)  The  tube  must  be  maintained  at  a  hardness  of  6  to  8  Walter, 
or  8  to  9  Bauer,  with  a  current  of  2  to  3  milHamperes. 

(2)  The  focus  skin  distance  should  be  not  less  than  38  cm.,  and  a  com- 
pression diaphragm  should  always  be  used. 

(3)  A  cycle  of  irradiations  should  be  given  consisting  of  a  separate 
exposure  on  three  areas — the  centre  and  each  side  of  the  lower  abdomen. 
This  is  best  carried  out  by  giving  an  irradiation,  each  of  about  six  minutes,  on 
three  consecutive  days.  The  whole  cycle  of  irradiation  must  never  exceed 
eighteen  minutes. 

(4)  There  should  be  an  interval  of  at  least  fourteen  days  between  each 
cycle  of  irradiation. 

(5)  A  subsequent  irradiation  must  be  given  only  if  the  skin  is  quite  pale 
and  shows  no  sign  of  reaction. 

(6)  The  skin  of  the  abdomen  should  always  be  guarded  by  a  thick 
leather  filter. 

Six  minutes'  exposure  under  the  above  condition  is  equivalent  to  2  to 
2-5  X.  This  would  give  6  to  7-5  X  for  the  three  days'  cycle,  an  amount 
well  under  the  erythema  dose  of  10  X  Kienbock. 

Technique  for  Uterine  Fibroids  {Haenisch).—'Weh.nelt  break. 
Penetration  of  tube  6  to  8  Walter  or  7  to  9  Bauer,  and  a  current  of  1-|  to 
2  milhamperes.  Filter  of  thick 'sole -leather  or  1  mm.  aluminium,  with  an 
addition  of  one  to  two  layers  of  chamois  leather. 


UTERINE  FIBROMATA  321 

Each  series  comprises  four  .sittings,  which  are  given  on  four  consecutive 
days,  preferably  beginning  just  after  the  menses,  a  sitting  lasting  for  five  to 
six  minutes.  The  skin  focus  distance  is  36  cm.  Slight  compression  is  used 
by  means  of  the  compression  cylinder  and  a  loofah  pad. 

During  each  series  a  total  dose  of  5  to  10  X  Kienbock  is  reached.  In  the 
latter  stages  of  the  treatment  the  series  often  consist  of  three  instead  of 
four  sittings.     Between  the  series  from  fourteen  to  twenty-one  days  elapse. 

When  the  tumours  are  very  large,  or  in  special  cases  when  rapid  effect 
is  necessary,  treat  in  several  directions,  i.e.  on  both  sides,  the  centre,  and 
also  through  the  back. 

Comparison  of  various  units  of  measurement : — 

X=unit  of  Kienbock  Quantimeter. 
10  X=Sabouraud  tint  "B  "  or  5  H. 

Technique  for  Uterine  Fibroids  (Bordier). — The  X-ray  irradiation 
is  carried  out  in  a  series  of  cycles,  each  cycle  comprising  nine  separate  irradia- 
tions of  the  median  region  of  the  abdomen  and  the  iliac  regions.  There 
are  thus  three  ports  of  entry  for  the  X-rays,  one  median  and  two  lateral, 
the  cycle  of  nine  irradiations  being  given  each  month  in  the  interval  between 
the  menstrual  periods. 

The  two  most  important  factors  are,  firstly,  the  dose  of  X-rays,  and 
secondly,  the  filtration  of  the  rays.  Bordier' s  technique  has  at  last  been 
perfected  so  that  the  incident  dose — that  is  the  dose  falling  on  the  aluminium 
filter — shall  be  always  the  same,  and  easily  measurable.  All  that  remains, 
then,  is  to  choose  the  appropriate  filter  according  to  the  order  of  series  and 
the  precise  number  of  the  cycle. 

As  regards  the  median  area,  or  port  of  entry,  Bordier  adds,  always 
employ  the  same  thickness  for  the  aluminium  filter,  viz.  3-5  milHmetres. 
This  region  should  always  be  carefully  protected,  so  that  the  skin  may  not 
be  injured  in  case  a  subsequent  operation  should  be  required. 

As  regards  the  lateral  ports  of  entry  at  the  flanks,  the  thickness  of  the 
filter  will  vary  from  |  millimetre  to  3  millimetres.  The  aluminium  filter, 
placed  on  the  abdomen,  is  connected  to  the  earth  by  means  of  a  flexible 
metallic  wire.  The  dose  of  the  incident  rays  may  be  measured  with  great 
facility  by  means  of  Bordier's  radiometer.  The  pastille  is  stuck  on  to  the 
filter  itself,  and  the  dose  to  be  given  corresponds  to  tint  3  of  Bordier's  scale, 
which  is  exactly  equivalent  to  5  H.  The  pastille  should  be  compared  with 
the  scale  by  the  light  of  a  match,  a  candle,  a  benzine  lamp,  or  other  artificial 
light  of  slight  actinic  power. 

The  Rontgen  bulb  should  always  be  placed  at  the  same  distance  from 
the  filter  ;  a  convenient  distance  is  the  breadth  of  the  hand,  the  four  fingers 
being  interposed  between  the  bulb  and  the  filter.  Bordier  employs  a 
water-cooled  Mliller  tube  16  centimetres  in  diameter,  regulated  so  as  to 
emit  rays  of  penetration  8°  to  10°  Benoist. 

Filtration. — The  following  table  shows  Bordier's  formula  of  filtration 
for  each  lateral  port  of  entry  of  the  X-rays  on  their  way  to  the  ovary  : 

21 


322 


RADIATION  THERAPEUTICS 

Incident  Dose  on  the  Flank  5  H 


Irradiation. 

First 

Second 

Third 

First  cycle 
Second  cycle     . 
Third  cycle 
Fourth  cycle 
Fifth  cycle 

mm. 
0-5 
0-5 
1-0 
2-0 
2-5 

mm. 
0-5 
1-0 
1-5 
2-5 
3-0 

mm. 
1-0 
1-5 
2-0 
3-0 
3-5 

The  dose  incident  on  the  filter  being  5  H,  and  the  absorbent  power  of 
the  filter  being  known,  it  is  easy  to  calculate  the  total  quantities  received, 
by  the  right  and  left  fianks  respectively  during  each  cycle.  The  time  required 
to  obtain  the  dose  5  H  should  not  exceed  five  or  six  minutes. 

During  the  irradiation  of  the  lateral  regions  the  median  region  of  the 
abdomen  is  protected  by  a  strip  of  lead,  the  edges  of  which  should  extend 
at  least  two  fingerbreadths  to  either  side  of  the  middle  line. 

The  seances  are  to  be  given  one  each  day.  There  should  be  an  interval 
of  at  least  three  weeks  between  each  cycle.  As  regards  injury  to  the  skin, 
even  at  the  end  of  the  fourth  cycle  of  irradiations  there  is  only  a  slight  brown 
coloration  ;  Bordier  has  in  no  case  seen  the  slightest  sign  of  radio-dermatitis. 

Freiburg"  Technique  for  Uterine  Fibroids. — Gauss  and  Lembcke 
of  Freiburg  employ  a  different  technique  ;  a  summary  of  this  is  quoted 

below. 

The  methods  employed  consists  briefly  of  a  series  of  exposures  given 
at  one  sitting,  which  lasts  from  two  to  three  hours.  These  are  repeated  at 
intervals  of  three  weeks.  Three  or  four  seances  are  sufficient  to  end  in  a 
complete  cure  (it  is  claimed)  in  a  large  percentage  of  cases  treated.  The 
chief  points  are  : 

(1)  The  treatment  of  the  abdominal  wall.  Great  care  must  be  exercised 
so  as  not  to  damage  the  skin. 

(2)  Many  points  of  entrance  are  considered  necessary.  These  are 
arranged  so  that  a  maximum  effect  is  obtained  on  the  deeper  structures 
while  the  skin  is  not  damaged. 

The  points  taken  are  the  umbilicus  and  the  brim  of  the  pelvis.  A  line 
drawn  across  the  abdomen  at  the  level  of  the  umbilicus  forms  the  upper 
limit  of  irradiation.     Thus  : 


9 

5 

6 

7 

10 

4 

3 

8 

11 

1 

2 

12 

The  mid-areas  are  treated  with  the  tube  at  right  angles  to  the  body, 


DISEASES  OF  THE  BLOOD  323 

the  lateral  areas  with  the  patient  turned  on  the  side,  and  the  tube  pointed 
obliquely  inwards. 

Six  areas  are  marked  out  on  the  back  and  the  patient  placed  on  the 
abdomen,  the  tube  operating  from  above. 

The  skin  is  protected  by  means  of  T-shaped  pieces  of  lead  2  mm.  thick. 
These  should  be  covered  with  lint  to  prevent  secondary  radiation  effects 
upon  the  skin. 

Several  layers  of  satrap  paper  are  arranged  on  the  surface  of  two  or 
more  layers  of  loofah  sponge,  and  the  whole  is  embedded  in  lint  or  paper. 
The  Kienbock  slip  is  placed  on  the  skin  underneath  the  above  filters.  The 
filter  is  laid  over  the  area  of  exposure,  and  the  tube  is  placed  in  a  specially 
constructed  efficiently  protected  tube  box,  fitted  with  good  mechanical 
movements.  The  distance  between  the  anticathode  and  the  skin  should 
be  20  cm. 

Ten  to  twelve  areas  may  be  treated  from  the  front  and  six  from  the 
posterior  aspect.  An  aluminium  filter  of  3  mm.  thickness  is  used.  The 
dose  to  each  area  should  be  10  to  20  X.  Taking  18  areas  at  say  15  X  this 
gives  270  X  at  one  sitting.  After-effects  must  be  looked  for  when  using 
these  large  doses.  The  patient  should  be  kept  in  bed  for  a  day  or  two 
after  the  treatment. 

The  time  taken  to  obtain  10  to  20  X  on  the  sldn  will  depend  upon  the 
hardness  of  the  tube  used  and  the  quantity  of  current  passing  through  it. 

At  Freiburg  the  usual  method  employed  is  to  give  five  minutes  to  each 
area,  5  to  6  milliamperes  being  passed  through  a  tube  of  a  hardness  of  7  to  9 
Bauer. 

It  is  not  necessary  to  develop  the  paper  for  each  dose.  The  total 
number  exposed  should  be  developed  at  the  end  of  the  sitting,  and  the  total 
dose  can  be  easily  ascertained  at  a  later  period.  The  method  of  Kienbock 
gives  us  a  means  of  obtaining  a  permanent  record  of  the  total  dose  given. 

Specially  selected  tubes  are  necessary,  and  a  good  supply  of  tubes  must 
be  at  hand.  These  may  require  to  be  changed  frequently,  especially  in  the 
early  stages  of  their  life.  Later  on  one  tube  may  give  several  doses  in 
succession.     A  thorough  system  of  cooling  must  be  employed. 


THE  TREATMENT  OF  DISEASES  OF  THE  BLOOD 

Badiations  either  of  X-rays  or  radium  are  used  in  the  treatment  of 
diseases  of  the  blood,  with  in  some  cases  a  marked  improvement  in  the 
condition.  It  is  impossible  to  deal  at  any  length  with  all  the  conditions  of 
alteration  in  the  blood  and  the  associated  changes  in  the  spleen  and  bone 
marrow.  A  short  resume  of  some  of  the  conditions  calling  for  radiation 
treatment  will  suffice  for  the  present,  particular  attention  being  paid  to 
those  which  are  known  to  respond  to  these  radiations.  The  technique  used 
will  vary  in  individual  cases.  Hard  tubes  should  be  employed,  and  if 
repeated  radiations  are  necessary,  filters  should  be  used. 


324  EADIATION  THERAPEUTICS 

In  the  treatment  of  a  condition  whicli  is  general  in  its  effects  and  of 
wliicli  the  pathology  is  obscure,  or  where  the  morbid  changes  originate  in 
the  spleen,  glands,  and  bone  marrow,  the  rational  plan  is  to  treat  large 
areas  of  the  body  rather  than  to  centre  upon  one  particular  organ  such  as 
the  spleen. 

This  plan  allows  of  much  larger  doses  being  administered  and  prevents 
the  occurrence  of  any  local  damage,  which  may  easily  be  caused  when  one 
organ  or  area  alone  receives  the  irradiations.  In  these  cases  the  skin  is 
apt  to  be  seriously  damaged  and  treatment  has  to  be  suspended. 

On  general  principles,  therefore,  it  is  well  to  give  the  splenic  area  a 
thorough  irradiation  and  then  proceed  to  deal  with  other  regions.  When 
the  spleen  is  greatly  enlarged  the  skin  area  over  it  may  be  divided  into 
several  sections,  and  each  receive  a  dose  in  turn.  The  ends  of  the  long 
bones  may  be  treated  through  the  surface  by  using  hard  tubes  and  filters. 
The  glands  of  the  axilla,  groin,  and  neck  may  also  be  thoroughly  irradiated. 

Duration  of  Treatment. — At  the  commencement  of  treatment  a  dose 
may  be  given  twice  a  week  for  about  six  weeks.  Care  should  be  taken  to 
change  the  areas  as  frequently  as  possible.  Treatment  is  then  suspended 
for  two  or  three  weeks.  At  the  end  of  that  time  one  or  several  doses  may 
be  given,  and  the  patient  kept  under  observation  for  another  three  weeks. 

In  treating  leukaemia,  etc.,  a  careful  watch  should  be  kept  upon  the 
blood,  counts  being  made  at  regular  intervals.  A  differential  count  should 
always  be  made.  Cases  which  respond  well  to  treatment  should  be  carefully 
watched  over  long  periods  of  time,  and  on  no  account  should  treatment  be 
entirely  suspended  for  any  length  of  time.  These  cases  relapse  even  when 
regular  treatment  is  carried  out,  but  are  less  likely  to  do  so  when  the  action 
is  kept  up  by  giving  regular  doses  at  intervals  of  a  month  or  six  weeks. 

It  would  appear  that  when  the  tissues  have  received  benefit  from  radiation 
treatment,  they  require  a  regular  repetition  to  maintain  the  improvement. 
Patients  appear  to  miss  the  stimulating  efiects  when  treatment  is  suspended. 

Pernicious  Anaemia. — In  this  disease  the  effects  of  X-rays  upon  the 
blood-forming  organs,  i.e.  the  spleen  and  the  marrow  of  the  long  bones,  may 
sometimes  be  of  great  benefit.  Great  care  must,  however,  be  exercised  in 
these  cases.  Stimulating  doses  are  required.  Small  doses  of  a  penetrating 
ray  at  frequent  intervals  may  be  beneficial  by  acting  as  a  stimulant  to  the 
blood-forming  organs. 

Careful  and  frequent  blood  counts  must  be  the  rule,  and  if  no  marked 
improvement  results  from  a  few  exposures  treatment  must  be  suspended. 
The  fact  must  be  well  borne  in  mind  that  large  doses  may  precipitate  a 
fatal  termination  by  inducing  a  toxsemia. 

Hodgrkin's  Disease. — This  is  an  affection  characterised  by  a  pro- 
gressive enlargement  of  the  lymphatic  glands  (beginning  usually  on  one 
side  of  the  neck)  and  spleen,  with  the  formation  in  the  liver,  spleen,  lungs,  and 
other  organs  of  nodular  growths  associated  with  a  secondary  ansemia  without 
leukaemia. 

This  disease  is  very  responsive  to  X-ray  treatment,  and  if  radiated 


DISEASES  OF  THE  BLOOD  325 

sufficiently  early  in  the  course' of  the  disease,  marked  improvement,  arrest 
of  progress  for  a  lengthy  period,  and,  in  a  percentage  of  cases,  cure  may  result. 

The  beneficial  efiect  of  the  X-rays  is  due  to  a  direct  action  upon  lym- 
phatic tissue  and  to  an  effect  upon  tissue- ferments.  The  action  upon  tissue- 
ferments  may  be  directly  a  result  of  the  ray  action  upon  the  blood  cells  ; 
consequently  in  this  disease  it  is  well  to  treat  large  areas  of  the  body  surface 
as  well  as  the  particular  group  of  enlarged  glands.  A  marked  diminution 
in  the  size  of  enlarged  glands  may  be  induced  when  only  remote  regions  of 
the  body  are  treated. 

In  all  these  cases  it  is  well  to  begin  treatment  by  giving  frequent  small 
doses,  in  order  to  ascertain  the  degree  of  response  to  the  radiations  before 
proceeding  to  give  large  filtered  doses.  Should  the  response  be  favourable, 
the  more  penetrating  ray  may  then  be  employed  in  various  situations. 
A  dose  once  a  week  should  be  sufficient,  several  large  areas  being  treated  at 
one  time.     In  most  cases  a  filter  should  be  employed,  |  mm.  to  1  mm.  thick. 

After  a  sufficient  number  of  doses  have  been  administered,  treatment 
should  be  suspended  for  a  time  (two  or  three  weeks).  After  this,  treatment 
should  be  continuous,  a  dose  being  given  once  a  fortnight  for  several  months 
so  long  as  the  disease  appears  to  be  quiescent.  Should  a  relapse  occur  it 
will  be  necessary  to  resume  the  same  or  more  frequent  and  larger  dosage. 

Leukaemia. — An  affection  characterised  by  a  persistent  increase  in 
the  number  of  white  blood  corpuscles,  associated  with  changes,  either  alone 
or  together,  in  the  spleen,  lymphatic  glands,  or  bone  marrow.  There  are 
two  main  types,  though  combinations  and  variations  may  occur : 

(1)  Spleno-Medullary  Leukcemia. — In  this  form  the  changes  are 
specially  localised  in  the  spleen  and  the  bone  marrow,  while  the  blood  shows 
a  great  increase  in  elements  which  are  derived  especially  from  the  latter 
tissue,  a  condition  which  Miiller  has  termed  "  myelsemia."  Ehrlich  calls 
this  type  of  the  disease  myelogenous  leukaemia, 

(2)  Lymphatic  Leukaemia. — Here  the  changes  are  chiefly  localised  in 
the  lymphatic  apparatus,  the  blood  showing  an  increase  in  those  elements 
derived  from  the  lymph  glands. 

In  the  spleno-medullary  form  the  spleen  is  greatly  enlarged,  the  organ 
being  in  a  condition  of  chronic  hyperplasia.  There  is  also  marked  hyperplasia 
of  the  bone  marrow. 

In  the  lymphatic  form  there  is  a  general  lymphatic  enlargement, 
which  is  usually  associated  with  a  certain  amount  of  enlargement  of  the 
spleen. 

It  is  necessary  to  describe  the  blood  changes  in  this  disease,  but  it  must 
be  clearly  understood  that  remarkable  fluctuations  occur  both  in  the  relative 
percentage  of  cells  in  the  blood,  and  in  the  size  of  the  spleen,  in  cases  which 
receive  no  treatment.  Caution  must  therefore  be  exercised  in  attributing 
improvements  to  radiation  treatment  which  may  represent  only  the  normal 
fluctuations  of  the  disease.  When  thorough  radiation  treatment  is  carried 
out,  marked  improvements  may  sometimes  be  induced,  and  the  spleen 
often  diminishes  in  size.     Bearing  in  mind  the  analogy  between  this  disease 


326  RADIATION  THERAPEUTICS 

and  sarcoma,  it  would  appear  tliat  leuksemia  is  really  a  malignant  disease 
of  ttie  blood. 

This  fact,  no  doubt,  accounts  for  the  ultimate  failure  to  cure  in  nearly 
all  the  cases  treated.  Relapses  occur  from  time  to  time  which  may  respond 
again  and  again  to  further  treatment,  but  in  the  end  the  disease  baffles  the 
remedy. 

During  the  course  of  treatment  by  radiations,  differential  blood  counts 
should  always  be  made,  and  a  rapid  fall  to  normal  should  be  an  indication 
for  the  suspension  of  treatment. 

The  Nature  of  the  Action  of  X-rays  in  Blood  Diseases. — Krauss  and 
Zeigler  explain  the  action  as  being  a  destruction  by  the  radiations  of  the 
pathological  lymphoid  tissue.  Edouel  attributes  the  effect  to  an  action 
upon  the  tissue  ferments. 

The  analogy  between  this  action  upon  blood  cells  and  that  upon  the 
cells  of  a  new  growth  is  striking.  In  both  instances  the  new  cells  are  being 
produced  at  an  abnormally  rapid  rate,  and  presumably  their  power  of 
resistance  to  radiations  is  much  lower  than  it  is  when  cells  are  produced 
at  a  lower  rate,  and  therefore  they  are  more  easily  destroyed.  Melchener 
and  Wolff  found  that  a  spleen,  which,  after  removal  from  the  living  body, 
was  exposed  to  radiations,  yielded  a  leukotoxin,  which,  injected  into  a 
healthy  animal,  produced  a  marked  reduction  in  the  number  of  leucocytes, 
while  a  similar  injection  from  a  spleen  which  had  not  been  irradiated  produced 
a  leucocytosis,  increasing  the  number  of  white  blood  cells. 

Beclere  emphasises  the  necessity  for  the  continuance  of  treatment 
over  long  periods  of  time,  in  spite  of  an  early  apparent  disappearance  of 
symptoms.  He  found  that  under  X-ray  treatment  the  blood  condition 
improved,  the  general  health  markedly  improved,  colour  was  regained,  there 
was  a  rise  in  the  number  of  the  red  cells,  and  the  nucleated  red  cells  dis- 
appeared. 

Megaloblasts  and  young  cells  disappear  early,  the  normoblasts  being 
a  little  more  tenacious.  The  presence  of  the  solitary  myelocytes  should 
correct  the  hasty  impression  that  the  disease  has  been  vanquished,  but 
he  has  seen  cases  which  had  been  treated  for  six  years  and  remained  well. 
Although  there  are  relapses  these  are  frequently  ameliorated  by  further 
treatment. 

Panton  and  Tidy  have  made  some  observations  on  the  results  of  treat- 
ment which  are  of  great  value.  Treatment  by  arsenic  and  X-rays  produced 
in  some  cases  :  (1)  no  alteration  in  the  condition  ;  (2)  a  remarkable  though 
temporary  improvement.  The  treatment  occasionally  precipitated  the 
fata]  issue.  The  most  interesting  blood  change  observed  was  the  replace- 
ment of  the  typical  granular  cells  by  non-granular  myeloblasts  shortly 
before  death. 

In  those  cases  in  which  marked  effects  were  produced  by  treatment  it  is 
open  to  doubt  whether  that  effect  was  beneficial.  In  some  cases  treatment 
was  followed  by  effects  the  reverse  of  beneficial.  Panton  and  Tidy  emphasise 
the  point  that  a  diminution  in  the  number  of  leucocytes  and  size  of  the 


DISEASES  OF  THE  LUNGS  AND  MEDIASTINUM  327 

spleen  is  not  necessarily  evidence  of  improvement  but  may  be  the 
reverse. 

A  drop  in  the  total  number  of  leucocytes  with  a  relative  increase  in  the 
myeloblasts  suggests  a  fatal  termination  in  the  near  future,  and  such  an  event 
may  result  from  treatment  in  a  case  apparently  progressing  favourably. 

The  blood  change  aimed  at  is  a  reduction  in  the  number  of  leucocytes 
to  a  number  approximately  equal  to  but  not  less  than  the  normal,  the 
relative  percentage  of  cells  being  unaltered.  A  rapid  diminution  in 
the  number  of  white  cells,  with  an  increase  in  the  percentage  of  non- 
granular, and  particularly  in  the  percentage  of  myeloblasts  is  an  indica- 
tion that  treatment  must  be  suspended.  This  need  only  be  temporary, 
for  after  a  time  the  white  cells  increase  again.  Treatment  repeated 
at  intervals  will  help  to  keep  the  disease  under  control.  Patients 
may  go  on  having  regular  doses  at  long  intervals  and  maintain  fairly  good 
health  for  years.  In  all  cases  the  dosage  should  be  controlled  by  the  chnical 
condition,  and  blood  counts  should  be  made  at  regular  intervals  during  the 
course  of  treatment.  This  enables  a  check  to  be  kept  on  the  radiation  dose, 
and  indicates  whether  a  long  or  short  exposure  is  advisable.  It  may  suggest 
that  treatment  be  suspended  for  a  time.  Patients  who  are  taking  arsenic 
internally,  or  who  have  recently  had  salvarsan,  should  be  carefully  watched 
while  undergoing  radiation  treatment.  Rapid  changes  may  be  induced  in 
the  blood  of  these  patients. 


THE  TREATMENT  OF  DISEASES  OF  THE  LUNGS 
AND  MEDIASTINUM 

Up  to  recent  times  the  radiation  treatment  of  diseases  of  the  thoracic 
and  abdominal  cavities  has  received  little  attention,  but  a  recognition  of  the 
marked  improvement  in  the  general  condition  of  patients  receiving  X-ray 
treatment  for  deep-seated  cancer,  fibromata,  and  other  conditions  has  led 
to  the  systematic  treatment  of  all  deep-seated  disease  by  X-rays. 

The  Enlarg-ement  of  the  Mediastinal  Glands  met  with  in  lymph- 
adenoma  and  primary  and  secondary  sarcoma  yields,  at  all  events  to  a  partial 
degree,  to  deep  radiations. 

All  conditions  of  tumour  should  be  treated  for  a  time  with  X-rays,  a 
thorough  technique  being  used  and  large  doses  with  hard  tubes  being  given. 
Marked  relief  may  often  be  obtained,  and  the  patient's  condition  much 
improved. 

The  thoracic  area  should  be  mapped  out  into  divisions  of  a  convenient 
size,  and  lead  screens  employed  to  protect  the  surrounding  skin.  A  filter 
of  3  mm.  of  aluminium  is  used,  and  the  tube  brought  as  near  as  possible  to 
the  skin  surface.  It  is  best  to  employ  a  hard  tube,  a  10  Bauer  if  possible, 
through  which  a  current  of  4  to  5  milliamperes  is  run.  Kienbock  paper 
should  always  be  used,  and  a  careful  record  kept  of  all  exposures  for  future  use. 

Ten  or  twelve  exposures  may  be  given  at  one  sitting  on  one  day,  followed 


328  EADIATION  THERAPEUTICS 

up  on  the  succeeding  days  with  as  many  exposures  as  it  is  possible  to  fit  into 
the  thoracic  area. 

When  the  front  of  the  chest  is  treated,  the  areas  are  marked  out  so  as  to 
include  the  intercostal  spaces  in  the  longitudinal  aspect  of  the  aperture. 
By  this  method  a  percentage  of  the  rays  get  in  through  the  intercostal 
spaces.  The  supra-clavicular  areas,  anteriorly  and  posteriorly,  may  be 
treated  in  the  same  way,  and  the  axillae  should  also  be  irradiated.  The 
posterior  thoracic  wall  should  be  mapped  out  and  treated  in  a  similar  manner. 

By  using  this  technique  it  is  possible  to  get  in  a  comparatively  large 
dose  up  to  or  exceeding  100  X  on  the  skin  surface  in  one  or  two  days.  The 
patient  should  be  confined  to  bed  for  a  day  or  two  after  each  series  of  radia- 
tions, and  a  watch  kept  on  the  pulse  and  temperature.  A  marked  reaction 
may  follow,  and  haemorrhage  may  even  occur  as  the  result  of  the  reaction 
to  the  stimulation,  but  this  slowly  subsides. 

In  the  intervals  of  treatment  the  patient  should,  if  possible,  be  in  the 
country,  living  an  open-air  life,  and  tonics  and  a  generous  diet  should  be 
insisted  upon.  The  result  of  treatment  on  these  lines  is  frequently  a  marked 
improvement  in  general  health,  with  a  sense  of  well-being  and  an  improve- 
ment in  spirits  ;  often  there  is  also  relief  of  pain,  and  in  some  cases  a  gain 
in  weight,  and  a  reduction  in  the  size  of  the  tumour. 

Sub-acute  or  Chronic  Tuberculosis  may  benefit  from  a  course  of 
radiation  treatment  combined  with  open-air  treatment. 

Lymphadenoma  often  responds  to  this  treatment  to  a  marked  extent, 
and  sarcomata  are  occasionally  arrested  in  their  progress  for  a  time  at  least. 

Endotheliomata  of  the  lung  or  pleura  are  the  most  likely  tumours 
to  benefit  from  radiations,  and  secondary  carcinoma  of  a  slow  growth  also 
appear  to  improve. 

In  the  future,  when  it  may  be  possible  to  use  still  harder  tubes  and  give 
longer  exposures  with  a  more  penetrating  ray  than  has  hitherto  been  done, 
it  may  be  hoped  that  greatly  improved  results  may  be  obtained.  This 
belief  is  supported  by  the  great  improvement  which  has  recently  taken 
place  in  the  treatment  of  malignant  disease  generally.  It  is  now  possible 
to  influence  favourably  by  X-rays  the  progress  of  many  cases  of  carcinomata 
which  a  few  years  ago  did  not  seem  to  improve  at  all.  This  improve- 
ment in  results  is  undoubtedly  due  to  the  following  improved  factors  in 
therapy  :  (1)  The  employment  of  very  hard  X-ray  tubes  ;  (2)  the  employ- 
ment of  fairly  thick  filters  ;  (3)  a  considerable  increase  in  the  dose  of  radia- 
tions ;  (4)  the  employment  of  many  ports  of  entry ;  (5)  the  increased 
frequency  of  treatment. 

In  many  cases  the  results  obtained  are  quite  as  good  as  those  obtained 
by  the  use  of  radium. 


B.    RADIUM    THERAPY 

PHYSICS   OF   RADIUM 

By  C.  E.  S.  Phillips,  F.R.S.E. 

When  a  radium  atom  has  become  unstable,  most  probably  through  the 
gradual  radiation  of  undetectable  energy  by  the  electrons  which  it  contains, 
the  new  condition  requires  a  rearrangement  of  its  constituent  parts,  accom- 
panied by  the  sudden  expulsion  of  an  electrified  atom  of  heham. 

The  spintharoscope  of  Crookes,  as  well  as  the  more  recent  methods  of 
Rutherford  and  Geiger,  enable  these  individual  atoms  of  electrified  helium 
to  be  counted  ;  they  may  even  be  caused  to  make  a  record  upon  a  moving 
photographic  film.  In  this  way  it  is  seen  that  they  are  not  expelled  by  the 
radium  atoms  with  perfect  regularity.  During  any  given  interval  of  time, 
however,  their  number  is  very  nearly  constant. 

Thus,  from  a  definite  quantity  of  radium  there  come  streams  of  electrified 
matter,  the  particles  of  which  move  at  about  12,000  miles  per  second,  carry- 
ing a  positive  charge,  and  constituting  the  well-kno^\^l  positive  or  Alpha  rays. 

It  may  be  pointed  out  at  once  that  it  is  the  writer's  intention  to  include 
in  this  section  only  data  which  seems  essential  for  the  purpose  of  describing 
the  broad  principles  underlying  the  appHcation  of  radium  to  medical  work. 
For  greater  detail,  reference  should  be  made  to  standard  works  on  radio- 
activity. It  is,  therefore,  thought  unnecessary  to  dwell  at  length  upon  the 
behaviour  of  the  products  of  radioactive  change  which  give  no  rays  of 
therapeutic  use,  nor  has  it  been  considered  advisable  to  attempt  any  elaborate 
summary  of  the  various  physical  properties  and  actions  of  radioactive  bodies 
generally. 

There  is  every  probability,  however,  that  some  better  way  will  be  found 
in  the  future  for  utilising  medically  the  great  kinetic  energy  of  the  Alpha 
particle,  and  in  view  of  that  possibility,  it  is  proposed  to  refer  more  in  detail 
to  the  properties  of  this  radiation  than  would  otherwise  have  been  necessary. 

In  any  mass  of  radium  some  of  the  atoms  are  extremely  stable,  while 
others  are  approaching  in  various  degrees  the  condition  which  ends  in  their 
disruption.  The  "  average  life,"  therefore,  of  a  radium  atom  means  the 
average  of  a  number  of  different  values,  ranging  from  seconds  to  thousands 
of  years.  It  is  curious  to  notice  that,  in  spite  of  violent  atomic  disturbances 
taking  place  around  them,  some  of  the  radium  atoms  should  remain  so  stable, 
and  especially  that  always  the  same  fraction  of  them  disintegrates  at  any 
given  period.  Experiment  has  shown  this  proportion  to  be  characteristic 
for  each  radioactive  substance,  and  holds  independently  of  whether  the 
atoms  are  compact  (as  m  a  solid)  or  \\Tidely  distributed  throughout  a  solution. 

329 


330  EADIATION  THEKAPEUTICS 

Further,  no  means  has  yet  been  found  whereby  the  rate  of  disintegration 
can  be  modified  in  the  least  degree.  Eeference  will  again  be  made  to  this 
question  when  the  meaning  of  the  "  half -period  "  and  other  radioactive 
constants  is  considered. 

The  atoms  of  all  forms  of  matter  may  be  regarded  as  minute  clusters  of 
still  more  minute  bodies  which  carry  electric  charges,  some  being  negatively 
and  others  positively  electrified. 

It  is  one  of  the  most  striking  facts  in  science  that  the  mass  of  these 
negatively  electrified  bodies,  as  well  as  the  charge  they  carry,  is  the  same 
wherever  they  occur,  for  they  can  be  driven  out  of  the  atoms  of  many  sub- 
stances and  their  properties  studied.  On  the  other  hand,  since  the  residue 
of  an  atom  which  has  lost  a  negative  body  or  electron  is  no  longer  neutral, 
but  contains  positive  electricity  in  excess,  the  positive  ions  are  associated 
with  groups  of  particles  and  have  never  been  successfully  isolated.  In 
general,  therefore,  their  mass  is  far  greater  than  that  of  the  electrons,  and 
their  movements  under  the  same  forces  are  proportionately  slower.  The 
electron  being  only  about  xsW*^  *^®  ^^^®  ^^  ^^  atom  of  hydrogen,  it  can  be 
realised  that  since  some  atoms  contain  but  a  few  electrons,  there  must  be 
plenty  of  room  for  the  movements  which  modern  atomic  theory  requires  in 
interpreting  the  results  of  experiments.  When  electrons  escape  from  a  radium 
atom  they  move  at  a  great  speed — approaching  the  velocity  of  light  (3  x  10^^ 
cm,  per  second) — and  therefore  penetrate  not  only  the  spaces  between  the 
atoms  of  other  substances,  but  even  traverse  the  atoms  themselves.  Their 
course  may,  however,  be  bent  by  a  magnet,  since  they  have  magnetic  fields 
surrounding  them  in  virtue  of  their  motion  and  electric  charge.  And,  in 
addition,  they  can  be  coaxed  to  a  greater  or  less  extent  from  almost  any 
substance  by  heating  or  beating  down  upon  it  waves  of  short  length,  such 
as  those  of  ultra-violet  hght  or  X-rays.  It  therefore  appears  from  many 
experiments  of  this  character  that  all  bodies  contain  electrons.  We  must 
point  out,  however,  that  the  term  "  radioactivity "  does  not  apply  to 
those  substances  which  require  an  external  stimulus  to  bring  forth  a  radiation 
from  them.  Its  use  should  be  exclusively  limited  to  cases  where  an  atom 
disintegrates  spontaneously,  whether  accompanied  by  the  emission  of  a 
radiation  or  not. 

It  would  therefore  be  inaccurate  to  describe  as  radioactive  the  pheno- 
mena of  tribo-luminescence,  or  thermo-luminescence,  or  the  light  given 
out  by  materials  which  have  previously  been  strongly  illuminated ;  nor  can 
it  be  strictly  applied  to  the  electrodes  of  a  vacuum  bulb  in  which  X-rays 
are  generated. 

The  deviation  of  a  ray  by  a  magnetic  or  electric  field  forms  a  direct 
experimental  proof  as  to  whether  we  are  dealing  with  ether  pulses  or  streams 
of  electrified  matter.  Radiations  in  the  nature  of  light  are  unaffected  by 
these  means  so  far  as  deviation  is  concerned.  The  path  of  Alpha  particles, 
however,  is  modified  very  slightly  by  a  magnet,  because,  owing  to  the  com- 
paratively large  mass,  the  velocity  of  the  positive  ions  is  far  less  than  that  of 
the  electrons. 


lONISATION  AND  RECOMBINATION  331 

A  magnetic  field  of  great  strength  is  therefore  necessary  for  the  devia- 
tion of  Alpha  rays.  On  the  other  hand,  a  small  magnet  will  suffice  to 
appreciably  affect  a  stream  of  Beta  particles,  and  in  addition,  in  the  case  of 
Beta  rays  from  Radium  salts,  owing  to  their  heterogeneous  nature  (different 
velocities),  a  stream  of  electrons  may  be  sorted  out  into  a  kind  of  spectrum 
by  this  means.  It  also  follows  that  the  Alpha  and  Beta  rays  are  deflected 
oppositely  by  a  magnet,  and  tend  always  to  travel  in  a  direction  at 
right  angles  to  the  lines  of  magnetic  force. 

In  virtue  of  their  electric  charges,  both  Alpha  and  Beta  rays  are  also 
deviated  by  an  electric  field.  The  methods  by  which  a  direct  experimental 
measurement  of  the  velocity  of  the  particles  comprising  both  kinds  of  rays 
is  made  depends,  in  fact,  upon  the  foregoing  reactions. 

lonisation  and  Recombination 

Now  we  have  seen  that  the  radium  atom  expels  another  atom  (of 
helium),  and  it  is  important  to  consider  the  effect  of  this  positively  electrified 
particle  when  projected  at  a  velocity  of  12,000  miles  per  second  amongst  the 
neutral  clusters  of  other  electrified  bodies  constituting  a  gas.  A  gas  is 
chosen  because  its  atoms  or  molecules  can  so  freely  move  relatively  to  one 
another  that  if  their  constituents  are  split  asunder  by  the  inrush  of  the  Alpha 
particles  their  regrouping  mil  not  occur  too  quickly  to  enable  the  new  con- 
dition to  be  in  some  way  detected.  As  a  crude  analogy  we  may  picture  a 
bullet  fired  into  a  space  hung  with  bags  of  flour.  After  the  passage  of  the 
shot  fine  dust  would  fill  the  air.  Some  such  commotion  is  certainly  produced 
when  an  Alpha  particle  strikes  against  the  atoms  of  a  gas  ;  the  latter  are  spht 
into  numerous  minute  fragments — the  electrified  dust  of  atoms — and,  in  the 
case  of  air  at  normal  pressure  and  temperature,  153,000  electrified  bodies, 
electrons,  and  positive  ions  are  liberated  to  move  actively  in  all  directions. 
Many  questions  of  great  interest  centre  round  the  mechanism  by  which 
bodies  are  detached  from  neutral  atoms  through  the  impact  or  close  proxi- 
mity of  other  changed  particles.  Above  all,  it  has  provided  a  direct 
experimental  method  of  attack  upon  the  hitherto  obscure  problem  of  the 
constitution  of  matter. 

lonisation  occurs  similarly  when  the  electrons  or  Beta  particles  traverse 
a  gas,  and  it  may  also  be  produced  (only  in  less  degree)  by  the  passage  of 
short-wave  ether  pulses.  But  it  only  takes  place  then  if  the  waves  of 
the  radiation  are  so  short  that  the  electrons  within  the  atom  can  gather 
energy  from  them,  and  thus  augment  their  movements  to  such  an  extent  that 
ultimately  they  become  detached,  and  fly  off  at  enormous  velocities  in  all 
directions. 

The  Alpha  particles  from  radium  are  completely  absorbed  by  3-5  cm.  of 
air.  In  other  words,  beyond  this  range  they  are  incapable  of  detection  by 
their  electrical  effects,  since  no  ionisation  of  the  gas  occurs.  The  range  of 
the  Alpha  particles  expelled  by  various  products  of  the  radium  series  depends 
in  each  case  upon  the  rate  at  which  the  product  disintegrates. 


332 


RADIATION  THERAPEUTICS 


It  must  be  kept  in  mind  that,  during  the  process  of  ionisation,  the 
numerous  electrified  particles  set  free  are,  in  virtue  of  their  mutual  attrac- 
tions and  repulsions,  continually  recombining  to  form  neutral  groups  again.  It 
is  evident,  however,  that  the  action  of  a  radiation  may  be  to  so  disturb  the 
normal  arrangement  of  the  constituents  of  atoms  that,  while  the  influence 
is  operative,  their  usual  properties  are  modified.  If,  in  fact,  the  density  of 
the  radiated  substance  is  relatively  great,  as  in  the  case  of  a  solid,  while 
the  number  of  atoms  breaking  up  per  second  is  also  far  more  than  with  a  gas, 
the  rate  of  recombination  is  also  enormously  increased  owing  to  the  much 
closer  proximity  of  the  molecules.  But,  on  the  other  hand,  some  of  the 
changes  produced  by  the  radiations  are  permanent,  since  the  new  groupings 
that  arise  become  comparatively  fixed  owing  to  limited  molecular  movement. 
It  is  therefore  interesting  to  notice,  for  instance,  the  change  in  colour 
of  glasses  and  other  substances  under  the  influence  of  certain  radiations, 
and  to  find  that  after  a  thorough  shaking  of  the  molecules,  sufficient  to 
increase  appreciably  their  mean  free  path,  obtained  by  the  application  of 
heat,  the  original  grouping  is  regained  and  the  colour  disappears.  Although 
this  refers  chiefly  to  alterations  in  the  physical  nature  of  a  substance, 
many  chemical  changes  are  also  produced,  presumably  by  upsetting  the 
arrangements  of  the  bonds  which  unite  atoms  into  definite  molecular  groups. 
It  should  now  be  clear  from  the  nature  of  ionisation  that  an  electrified 
wire  brought  into  a  mass  of  ionised  gas  will  be  diselectrified  by  attracting 

to  it  ions   of  the 
^^^  opposite      charge, 

and  will  repel  the 
others.  Thus, 
negatively  charged 
initially  the  wire 
will  attract  posi- 
tive ions,  an.d 
gradually  become 
neutral.  A  strip 
of  gold  or  alu- 
minium leaf  at- 
tached by  one  end 
to  such  a  wire  will 
stand  out  from  it 
when  the  wire  is 
electrified,  and 
therefore  a  very 
simple  method  of 
detecting  the  pres- 
ence of  ions  in  a 
gas  consists  in  ob- 
serving the  movement  of  the  free  end  of  the  gold  leaf  when  a  radioactive  body 
approaches  the  wire.     It  is,  in  fact,  the  basis  of  all  measurements  of  radio- 


FiG,  220. — Special  form  of  gold  leaf  electroscope. 
(For  description  see  p.  341.) 


RADIUM  EMANATION 


333 


activity,  and  the  electroscope'shown  in  Fig.  220  is  an  instrument  embodying 
this  principle.    Its  detailed  description  must,  however,  be  deferred  till  later. 


Radium  Emanation 

The  residue  that  remains  when  a  radium  atom  has  expelled  an  Alpha 
particle  is  no  longer  radium.  It  is  an  atom  of  a  new  substance.  The  pro- 
perty whereby  it  clung  originally  to  adjacent  atoms  and  in  the  aggregate 


Fig.  221. — Apparatus  for  pumping  off  and 
collectina;  radium  emanation. 


Fig.  222. — Combined  pump  and  apparatus 
for  concentration  of  radium  emanation 
by  liquid  air. 


constituted  a  solid  substance  is  absent  now,  with  the  result  that  the  new 
atom  wanders  off  and  exhibits  the  characteristics  of  a  gas.  It  is  Hghter  than 
Ra,  but  still  very  heavy.  The  atomic  weight  of  the  lost  hehum  being  four 
units  and  that  of  radium  226-4,  the  new  substance  has  an  atomic  weight  of 
226-4  -  4  or  222-4.  It  has  been  called  "  the  emanation,"  and  is  itself  radio- 
active. Radium  emanation  can  be  collected,  transferred,  and  generally 
manipulated  like  any  other  gas,  and  the  apparatus  for  this  purpose  is  shown 
in  Figs.  221  and  222. 

The  most  convenient  way  of  liberating  emanation  from  a  radium  salt 


334 


RADIATION  THERAPEUTICS 


is  to  dissolve  it  in  water  strongly  acidulated  with  hydrochloric  acid.  The 
solution  placed  in  the  bulb  1  (Fig.  221)  gradually  develops  a  supply  of  the  gas, 
which  may  be  pumped  ofi:  from  time  to  time,  and  collected  by  displacement  in 
the  tube  2,  before  removal  to  the  sparking  apparatus  represented  in  Fig.  223. 
Here  the  mixed  gases,  hydrogen  and  oxygen,  produced  by  the  decomposing 
action  of  the  emanation  upon  the  solution  are  recombined  to  water  by  the 

passage  of  a  small  electric  spark 
between  the  platinum  points 
1,  1,  and  the  volume  of  gas  to 
be  dealt  with  thereby  reduced 
to  about  one-fifth  its  original 
amount.  The  residue  consists 
mainly  of  hydrogen,  which  al- 
ways occurs  in  excess,  a  little 
water  vapour,  and  the  emana- 
tion. If  we  wish,  the  three  way 
stop-cock  can  be  turned,  and 
the  gas  driven  up  into  the  flat 
glass  tube  2,  also  shown  in  the 
diagram,  which  has  been  pre- 
viously exhausted  by  an  air 
pump.^ 

Another  method  of  collect- 
ing the  emanation  consists  in 
condensing  it  by  liquid  air  upon 
the  inner  surface  of  a  small  bulb, 
(1  in  Fig.  222).  When  the  bulb 
shows  by  its  strong  luminosity 
that  the  emanation  is  condensed 
(an  operation  that  only  takes,  a 
few  moments),  the  pump  can 
be  started,  and  the  whole  ap- 
paratus evacuated.  Tap  2 
should  then  be  turned  off  while 
tap  3  is  left  open,  and  the  bulb  is  withdrawn  from  the  liquid  air  and  held 
vertically.  The  emanation  will  rapidly  thaw  off  the  glass,  and  it  may  be 
driven  by  a  rising  mercury  column  into  the  very  small  glass  tube  above  the 
bulb  1,  which  is  then  sealed  by  a  flame  and  removed  for  use. 

The  emanation  expels  Alpha  particles,  but  they  cannot  penetrate  the 
glass  of  these  tubes,  except  in  very  special  cases.  The  expulsion  of  an  Alpha 
particle,  however,  causes  the  residue  to  coalesce  into  a  further  new  body 
called  Radium  A,  which  by  further  consecutive  changes  rapidly  gives  rise 
to  the  series  RaB,  RaC^,  and  RaCg- 

1  Always  lower  the  reservoir  when  the  mixture  has  passed  over  into  the  sparking  tube, 
so  that  the  gas  is  rarefied  before  sparking.  In  this  way  all  risk  of  dangerous  explosion 
is  avoided. 


Fig.  223. — Apparatus  for  charging  glass  or  other 
applicators  withiradium  emanation  atter  sparking. 


RADIUM  EMANATION 


335 


Now  RaC  {i.e.  RaC^  and-^RaCg  taken  together)  emits  not  only  Alpha 
particles  but  also  electrons  (/3  rays)  and  a  highly-penetrating  radiation  (7 
rays),  consisting  of  ether  pulses  of  extremely  short  length.  On  this  account 
Radium  C  is  of  the  greatest  importance  therapeutically.  The  streams  of 
electrons  from  it  can  easily  penetrate  the  thin  glass  of  the  tube,  but  they  are 
stopped  by  1-6  cm.  of  aluminium  or  -4  cm.  of  lead.  The  7  rays,  on  the 
other  hand,  are  about  a  hundred  times  more  penetrating.  The  above 
series  of  changes  requires  three  hours  for  its  completion,  and  at  the 
end  of  that  time  the  quantity  of  RaC  has  reached  its  equilibrium 
value.  But  from  the  moment  of  separation  from  the  parent  radium,  the 
emanation  itself  decays  by  a  process  of  disintegration  till  in  3-8  days 
only  half  of  it  is  left.  ,^ 
After  a  further  3-8  days 
half  of  what  remained  is  t 
gone,  and  so  forth.  It 
will  be  noticed  that  the  ' 
actual  amount  which  de- 
cays is  proportional  to  the 
quantity  present.  For  ^.^ 
instance,  if  we  have  two  z 
volumes  of  emanation,  g« 
one  being  twice  the  other,  | 
since  both  must  become  s' 

UJ 

reduced  to  half  their 
initial  values  by  the  end 
of  3-8  days,  the  amount  , 
of  emanation  which  dis- 
appears from  the  former 
is  twice  what  the  other 
loses  in  the  same  time. 
The  same  fraction,  how- 
ever, of  the  initial  quantity 
decays  in  both  cases.  An  exact  analogy  exists  in  the  lending  of  money 
at  compoimd  interest  if  we  can  imagine  the  capital  decreased  instead 
of  being  added  to  in  proportion  to  the  amount  at  the  moment.  Thus, 
£100  lent  at  10  per  cent  interest  payable  yearly,  on  this  plan,  would 
mean  that  at  the  end  of  the  first  year  £10  must  be  deducted  from 
the  capital,  leaving  £90  to  pay  interest  on  for  the  next  year.  At 
the  beginning  of  the  third  year  the  capital  would  be  reduced  to  £81 
after  the  deduction  of  10  per  cent  on  the  £90,  and  so  on,  the  amount 
deducted  being  always  proportional  to  the  capital.  If  we  plot  a  curve 
showing  the  gradual  dying  away  of  the  capital  in  this  case,  it  would  be 
a  curve  similar  in  character  to  that  in  Fig.  224,  which  really  represents  the 
decay  of  emanation  with  time,  the  quantity  disappearing  being  always 
proportional  to  the  amount  present.  This  relationship  is  of  fundamental 
importance  in  the  study  of  radioactivity.     It  may  be  put  in  another  way. 


TIME    IN    DAYS 


Fig.  224. — Curve  showing  decay  of  radium  emanation  with  time. 


336  RADIATION  THERAPEUTICS 

The  rate  at  which  the  emanation  decays  becomes  less  and  less  in  the  course 
of  time  ;  that  is  to  say,  the  actual  quantity  of  gas  decajdng  per  unit  time  is 
less  after  some  hours  than  it  was  at  the  instant  of  separation  from  the  parent 
radium.  In  Fig.  224  this  fact  is  represented  by  a  curve,  the  slope  of  which, 
though  steep  at  first,  gradually  becomes  flatter.  The  rate  of  change  of  the 
slope  must  therefore  represent  the  law  governing  the  decay  of  emanation 
with  time.  Now  we  know  from  experiment  that  the  gas  decays  to  half 
value  in  3-8  days,  so  that  calling  its  initial  quantity  100,  we  obtain  a  point 
on  the  curve  at  50.  A  further  wait  of  3-8  days  gives  another  point  on  the 
curve  at  25,  and  so  on.  Then  a  line  drawn  through  all  the  points  forms  a 
diagram  resembling  the  one  in  Fig.  224. 

By  taking  the  difference  of  any  two  consecutive  ordinates  representing 
say  an  interval  of  twenty-four  hours,  we  can  measure  approximately  the 
amount  of  emanation  decaying  during  that  time,  and  by  trial  over  the  whole 
range  of  the  curve  we  find  that  this  value  is  always  the  same  fraction  of  the 
mean  quantity  of  emanation  present  at  the  beginning  of  the  interval  chosen. 
The  accuracy  of  the  result  will  clearly  be  greater  if  the  time  interval  of  an 
hour  or  second  is  selected  instead  of  a  day.  Thus  by  this  graphic  method  we 
can  ascertain  approximately  the  value  of  the  constant  factor  (X),  which 
evidently  enters  into  the  expression  of  the  law  we  are  seeking,  and  see  in 
addition  that  the  rate  of  change  of  the  emanation  (slope  of  curve)  must 
always  be  equal  to  A,Q,  where  Q  is  the  amount  of  emanation  present  at  any 
instant.  Conversely,  if  both  the  value  of  \  per  unit  time  and  also  the  initial 
amount  of  emanation  contained  in  a  capsule  are  known,  we  can  plot  a  curve 
which  represents  the  gradual  decay  of  the  gas,  and  thus  ascertain  how  much 
remains  after  any  given  interval. 

But  the  exact  law  can  be  expressed  mathematically,  and  the  value  of  A, 
calculated,  provided  we  ascertain  experimentally  the  time  required  for  the 
emanation  to  decay  to  some  definite  fraction  (say  one-half)  of  its  initial 
quantity.     We  have 

dQ 


Integrating,  this  gives 


dt 
■\t=\og^Q+C (1) 


where  C  is  a  constant. 

But  if  Q  =Qo  when  ^  =0  then  C  =  -log,  Q„. 
Substituting  this  value  of  C  in  (1)  we  get 

-X^=log,  Q-log,  Q, 

-X^=log,S. 
Therefore,  Q 

/?  —  At 

Qo"  •     ■ 


(2) 


Suppose  now  we  know  that  if  t  =  3-8  days,  Q^  is  reduced  to  one-half  its  initial 
amount,  the  value  of  \  may  be  calculated  thus  : 


DECAY  OF  RADIUM  EMANATION  337 

Inverting  (2)  and  substituting  values,  we  have  : 

.-.       loge2=Xx3-8 
or,  •69=Xx3-8 

\  =  -18. 

A,  represents  the  fraction  of  the  emanation  decaying  per  day,  and  the  above 
result  is  of  great  importance  because  it  is  applicable  to  the  whole  range  of 
radioactive  substances,  each  having  a  characteristic  value  of  X  by  which 
it  may  be  identified. 

The  equation  also  represents  the  law  governing  the  absorbtion  of  a 
radiation  in  its  passage  through  the  tissues  or  other  media,  and  forms  in  fact 
the  only  criterion  by  which  it  can  be  determined  whether  a  radiation  is 
strictly  homogeneous  or  not.  If,  for  example,  by  interposing  a  series  of 
layers  of  aluminium  the  rays  are  not  cut  down  according  to  the  above 
law,  the  original  beam  must  have  contained  a  mixture  of  rays  of  different 
penetrabilities. 

So  far  we  have  only  considered  the  emanation  which  has  been  collected 
and  separated  from  its  parent  radium.  It  is  evident,  however,  from  the 
foregoing  considerations  that  the  quantity  of  emanation  associated  "uith  a 
given  amount  of  radium  mil  for  all  practical  purposes  reach  a  maximum 
value  within  a  definite  time. 

Beginning  with  the  case  where  all  the  emanation  has  been  initially 
driven  from  the  salt  by  heat  or  solution,  at  first  the  gas  will  accumulate 
rapidly,  for  we  have  seen  that  the  rate  at  which  it  disintegrates  is 
dependent  upon  the  quantity  present.  If  a  very  small  quantity  is  present 
the  number  of  atoms  disintegrating  mil  be  insignificant.  Meanwhile  the 
radium  is  producing  the  gas  at  a  rate  which  for  all  practical  purposes  may 
be  regarded  as  uniform  ;  and  as  it  slowly  accumulates,  the  quantity  of  it 
which  disintegrates  in  any  given  time  also  increases  (the  fraction  of  the 
whole  which  thus  breaks  up  remaining  constant),  until  a  point  is  reached 
when  a  state  of  equilibrium  is  maintained,  and  the  quantity  of  emanation 
disintegrating  per  second  is  equal  to  the  quantity  formed  by  the  radium 
in  the  same  time. 

It  does  not  matter  of  course  whether  the  salt  is  confiiied  in  a  large  or  a 
small  tube,  in  each  case  six  weeks  must  elapse  before  the  radium  and  emana- 
tion are  in  "  radioactive  "  equilibrium. 

It  is  therefore  usual  to  wait  for  that  time  before  measuring  the 
contents  of  a  tube  of  radium  salt  by  means  of  the  Gamma  rays  from  the 
product  RaCg,  which,  by  the  way,  only  requires  three  hours  to  reach  its 
equilibrium  value  with  the  emanation  producing  it.  We  are  in  any  case 
dealing  here  with  very  small  quantities  of  material.  The  quantity  of  radium 
emanation  in  equilibrium  with  1  gramme  of  radium  dementis  only  -58  cubic 
millimetre.  But  very  few  institutions  can  make  use  of  so  much  radium  as 
this.     An  operator  would  be  considered  fortunate  to  possess  100  mgrs. 

22 


338 


RADIATION  THERAPEUTICS 


of  radium  salt  for  emanation  work,  and  the  maximum  quantity  of  radioactive 
gas  that  could  be  obtained  from  that  each  month  would  be  -033  cm^. 
at  normal  pressure  and  temperature  ;  yet  this  incredibly  small  volume  of 
material,  which  would  go  into  a  pin's  head,  is  equivalent  for  a  short  while 
as  regards  Gamma  radiation  to  100  mgrs.  RaBrg. 

It  is  seen  therefore,  that  where  it  is  desired  to  irradiate  diseased  tissue 
from  within,  the  emanation  may  be  confined  in  small  glass  tubes  encased  in 
a  thin  pointed  platinum  cover  buried  in  the  growth.  The  radiation  close  to 
such  a  tube  is,  however,  very  intense,  and  in  cases  where  there  is  danger  of 
injuring  normal  tissue,  and  for  external  work  generally,  larger  tubes  are 
found  very  effective.  A  set  of  suitable  forms  is  shown  in  Fig.  229  (page 
348).  They  can  be  rapidly  made  at  the  glass  bench  to  suit  special  cases, 
and  have  the  additional  advantage  of  being  cleanly  and  light. 

After  the  emanation  has  decayed  to  a  value  too  low  to  serve  any  useful 

purpose,  the  tubes  may  be  opened  and  the  remaining  gas  collected,  so  that 

when  added  together  sufficient  may  be  obtained  to  charge  a  useful  applicator. 

If  it  is  desired  to  prepare   "  radium  water "   {i.e.   water  which  has 

absorbed   radium  emanation)   for  administration  in   accurate    doses,   the 

apparatus    represented    in   Fig.    225    has   been    found 

serviceable. 

The  bottle  1  is  connected  to  a  water-supply,  the  pres- 
sure of  which  is  sufficient  to  raise  the  mercury  in  the 
vessel  2.  The  volume  above  the  mercury  in  2  must  be 
known,  say  1-5  litres,  and  when  filled  with  water 
(rendered  slightly  alkaline  by  a  trace  of  bicarbonate  of 
soda),  taps  6  and  7  should  be  opened  while  all  the 
others  are  shut.  Now  owing  to  the  tendency  of  the 
mercury  to  run  back  into  the  Woulfe's  bottle,  air  will 
rush  up  into  the  liquid  if  tap  5  is  sHghtly  turned  on. 

If,  however,  instead  of  alloAving  air  to  enter  here,  it  is 
arranged  that  radium  emanation  alone  shall  bubble  up 
through  the  mercury  into  the  water,  the  taps  may  then 

be  closed,  and 
time  allowed 
for  the  gas  to 
be  absorbed. 
This  process 
can  be  greatly 
facilitated  by 
means  of  a 
spray  of  mer- 
cury coming 
from  the  fun- 
nel on  opening 
taps  3,  6,  and  7  with  tap  8  closed.  It  will  be  noticed  that  during  this  very 
perfect  mixing  the  volume  of  water  does  not  vary,  nor  is  it  exposed  to  the 


Fig.  225.- 


-  Arrangement  for  the  preparation  of  water  impregnated  with 
radium  emanation. 


RADIUM  SALTS 


339 


air.  The  only  gas  in  contact  with  it  is  the  small  bubble  of  hydrogen 
containing  the  emanation. 

The  solution  is  thus  soon  ready  to  be  drawn  off  from  the  side  tube  i, 
the  water  pressure  from  the  main  supply  forcing  up  the  mercury  in  2 
and  by  that  means  preventing  all  exposure  of  the  contained  liquid  to  the  air, 
except  during  the  few  seconds  necessary  for  the  process  of  botthng. 

The  bottles  used  to  hold  the  prepared  water  are  made  in  sets  of  graduat- 
ing size,  the  volumes  increasing  in  the  same  proportion  as  the  rate  at  which 
the  emanation  decays.  The  result  of  this  is  that  a  regular  dose  may  be  given 
twice  or  so  a  day  for  perhaps  a  week  with  one  set  of  bottles.  (For  strength 
of  radium  water  see  p.  343.)  The  radium  solution  from  which  the  emanation 
was  pumped  is  ever  giving  a  fresh  supply  ;  the  curve  showing  the  rate  of 
growth  is  the  complement  of  the  one  just  discussed.  We  can  say,  therefore, 
that  after  3-8  days  half  the  maximum  supply  is  available  ;  it  is  evidently 
more  economical  to  pump  the  gas  off  every  four-  days,  provided  that  -will 
give  sufficient  for  our  purpose,  than  to  wait  a  month  till  the  maximum  is 
reached. 

In  practice,  only  about  75  to  80  per  cent  of  the  emanation  may  be 
obtained  from  a  solution  in  the  manner  already  described.  By  boihng  the 
liquid  more  would  be  obtained,  but  the  risk  is  too  great.  The  coefficient  of 
solution  of  emanation  is  about  the  same  for  water  and  for  the  blood ;  salt 
water  takes  up  less  than  fresh  water,  but  oils,  paraffins,  charcoal,  and 
colloid  bodies  absorb  the  emanation  to  a  high  degree. 

It  may  be  well  to  give  here  a  brief  account  of  the  salts  of  radium  now 
in  use,  their  mode  of  packing  in  tubes,  and  their  relative  advantages.  The 
element  forms  an  insoluble  sulphate.  The  carbonate  is  also  practically 
insoluble.  To  convert  the  sulphate  into  a  soluble  form  it  may  be  boiled 
with  carbonate  of  soda,  dissolved  in  HCl,  and  crystallised.  This  gives  the 
very  soluble  salt  RaCl22H20.  Then  there  is  the  bromide,  RaBrg,  which 
is  difficult  to  obtain  free  from  water  of  crystalhsation ;  in  calculations, 
therefore,  use  the  formula  RaBr22H20. 

The  following  are  the  values  for  the  weight  of  radium  element  in  1  mgr. 
of  the  various  salts  : 


Name. 

Formula. 

Weight  of  Ra 
element  in  Mgrs. 

Radium  bromide 
Radium  chloride 
Radium  carbonate 
Radium  sulphate 

RaBr22H20 

RaClo2HoO 

RaCOg 

RaSO^ 

•585 
•679 
•790 
•702 

The  salts  are  generally  prepared  of  50  per  cent  purity.  It  is,  however, 
desirable  to  reduce  the  volume  of  the  crystals  as  much  as  possible,  and  the 
purification  should,  in  the  writer's  opinion,  be  carried  further.  This  practice 
(rarely  adopted)  results  in  the  radium  preparation  occupying  the  minimum 
volume. 

The  platinum  tubes  used   to  contain  the  salt  are  generally  -5  mm. 


340 


EADIATION  THERAPEUTICS 


thick  in  the  wall,  but  -3  mm.  will  just  carry  a  screw  thread,  and  if  made 
from  drawn  tube,  will  be  stifT  enough  for  most  purposes.  The  size  of  the 
tube  should  be  such  that  it  is  quite  filled  with  the  powder,  the  screw  plug 
being  then  inserted  and  gold-soldered  in  position.  It  is  essential  to  "  tin  " 
the  thread  with  gold  before  screwing  in  the  plug.  If  this  sealing  is  not 
perfectly  made,  emanation  will  escape  ;  this  may  be  detected  by  leaving  the 
tube  shut  into  a  box  for  a  few  days,  and  then  testing  to  see  whether  the 
interior  has  become  radioactive.  When,  however,  for  any  reason  it  is  required 
to  place  a  quantity  of  radium  salt  in  a  somewhat  long  narrow  tube  (metal), 
it  may  be  kept  in  position  by  a  plug  of  gold  leaf,  such  as  that  used  by  dentists 
for  tooth-stopping.  Or,  if  a  flat  applicator  is  needed,  Fig.  226  (A),  it  is  a  good 
plan  to  mix  the  salt  with  coco-nut  charcoal  before  filling,  for  by  absorbing 
the  emanation  this  ensures  a  uniform  radiation  from  the  faces  of  the  tube. 
For  insertion  into  deep-seated  regions  lengths  of  "  fine  "  silver  rod  should  be 
screwed  into  the  applicator  or  tubes.     "  Standard  "  silver  is  far  too  stiff. 

A  tube  of  platinum,  whose  wall  is  -5  mm.,  cuts  off  75  per  cent  of  the 
Beta  rays  and  4  per  cent  of  the  Gamma.  Four  mm.  of  lead  absorb  all  the 
Beta,  and  2  mm.  are  generally  safe  for  a  twenty-four  hour  exposure,  where 
little  or  no  skin  reaction  is  required.  Two  mm.  of  rubber,  or  five  layers  of 
lint,  seem  sufficiently  effective  in  suppressing  the  secondary  rays  from  the 
lead.     One  mm,  of  lead  reduces  the  Gamma  rays  by  4-5  per  cent. 

Unlike  X-rays,  the  Gamma  radiation,  being  practically  homogeneous, 
follows  the  density  law  of  absorption,  so  that  lead  and  silver  absorb  very 
nearly  the  same  amounts  for  equal  thicknesses.  The  coefficient  of  absorp- 
tion of  Gamma  rays  from  RaCa  by  lead  =-51,  while  that  for  the  Beta  rays 


V_J 

A 

c 


;  Fig.  226. — Various  forms  of  radium  applicators. 

varies  in  the  case  of  aluminium  between  13  and  53  (the  Beta  rays  being 
heterogeneous). 

A  filter  and  screen  in  use  at  King's  College  Hospital,  and  designed  by 


THE  ELECTROSCOPE  341 

the  writer,  is  represented  in  Fig.  226  (B).  It  consists  of  a  block  of  silver,  cut 
as  shown,  and  bored  out  to  take  two  fine  tubes  of  radium  salt.  The  thickness 
behind  the  tubes  is  1  cm.,  and  each  of  ten  platinum  shutters  (one  is  shown 
dotted  on  the  diagram)  can  be  slid  down  to  screen  the  radium  effectively. 
An  oval  section  filter,  Fig.  226  (C)  to  carry  two  tubes  is  also  found  to  be 
useful  at  the  same  Institution.  In  order  to  ascertain  the  quantity  of  radium 
contained  in  tubes  or  applicators,  it  has  become  necessary  to  devise  methods 
which  may  be  applied  without  in  any  way  disturbing  the  radioactive  salts 
to  be  tested. 

Measurement 

The  electroscope  shown  in  Fig.  220  may  now  be  described  in  detail.  It 
consists  essentially  of  a  lead  barrel  1  cm.  thick  (1),  pro\aded  with  lead 
windows  at  each  end,  and  glass  windows  at  the  sides.  A  fine  rod  stands 
erect  within,  carr\dng  a  piece  of  glass  fibre  rendered  electrically  conducting 
(or,  of  course,  a  gold  leaf).  This  stem  is  supported  by  a  plug  of  sulphur, 
and  projects  downwards  a  little,  so  that  the  piston  (2)  can  be  moved  up  by 
rotating  the  cam  (3),  and  thus  connect  the  leaf  stem  vnth.  batteries.  On 
lowering  the  stem  this  connection  is  broken,  the  brass  guard  tube,  however, 
remaining  charged. 

It  is  seen  that  no  electricity  can  leak  away  from  the  stem  except  by 
ionisation  taking  place  within  the  instrument,  owing  to  radiation  entering 
by  the  lead  windows.  There  will,  of  course,  be  a  natural  leak  (N_),  due  to 
slight  radioactivity  of  the  air  and  inner  surface  of  the  lead.  But  if  old  lead 
be  used,  this  leak  may  be  reduced  to  a  very  small  value.  The  cam  is  operated 
by  twisting  the  rod  (4)  between  two  stops.  The  movement  of  the  leaf  is 
read  by  a  microscope.  Great  care  should  be  taken  to  see  that  the  air  of  the 
room  is  still  when  the  electroscope  is  used,  or  otherwise  differences  of  tem- 
perature upon  different  sides  of  the  instrument  will  set  up  air  currents 
within,  which  vitiate  the  results.  And  it  is  essential  to  leave  the  leaf 
charged  for  a  few  hours  before  making  a  test.  Owing  to  the  curious  tendency 
of  insulators  to  soak  up  electric  charges,  time  must  be  allowed  for  the 
sulphur  to  become  saturated  before  beginning  work. 

The  lead  barrel  being  connected  to  earth,  readings  are  taken  when  each 
of  the  two  quantities  of  radium  to  be  compared  stand  at  some  definite 
distance  from  one  of  the  lead  windows,  and  a  comparison  of  these  results,  if 
one  of  the  radium  tubes  has  been  standardised  against  a  known  quantity  of 
pure  radium  salt,  will  enable  the  quantity  in  the  other  tube  to  be  determined. 
It  would  be  scarcely  appropriate  to  go  into  great  detail  here  as  to  this  matter, 
but  it  must  be  pointed  out  that  several  precautions  have  to  be  taken.  The 
avoidance  of  air  currents,  the  allowance  for  "  soakage,"  the  correction  for 
the  N_  must  all  be  attended  to.  The  charge  upon  the  "  guard  tube  "  should 
remain  constant,  and  for  that  purpose  a  set  of  200  Leclanche  batteries 
answers  well  (No.  3  size). 

The  most  important  condition  of  all,  however,  is  that  we  charge  the 


342  RADIATION  THERAPEUTICS 

leaf  stem  to  a  suflB.cient  potential  to  enable  it  to  attract  all  the  ions  of  opposite 
sign  as  quickly  as  they  form  in  the  gas  within  the  apparatus.  A  good  way 
to  test  this  consists  in  measuring  the  ratio  of  the  ionisation  produced  by 
Gamma  rays  from  two  specimens  of  radium  salt,  one  of  which  weighs  about 
twice  as  much  as  the  other. 

When  brought  close  to  the  electroscope  the  ionisation  due  to  the  rays 
from  the  larger  quantity  may  be  so  great  that  all  the  ions  are  not  caught 
before  appreciable  recombination  occurs,  whereas  the  lesser  tube  will  give 
fewer  ions,  all  of  which  may  be  attracted  to  the  leaf  stem. 

It  is  obvious  that  the  readings  then  will  not  give  the  true  value  for  the 
ratio  of  the  quantities  of  radium  present.  At  a  greater  distance,  however, 
the  correct  result  is  obtained,  and  beyond  that  point  no  further  change  in 
the  ratio  should  be  observed. 

By  this  means  experience  will  show  at  what  rate  the  leaf  should  fall  to 
ensure  working  within  a  safe  margin.  When  all  the  ions  are  caught,  the 
current  which  traverses  the  gas  in  the  electroscope  is  called  the  "  saturation 
current,"  and  exactly  what  value  it  must  have  in  each  particular  case  depends 
simply  upon  the  potential  gradient  between  the  charged  leaf  stem  and  the 
walls  of  the  electroscope.  If  the  stem  is  charged  to  300  volts,  the  case  being 
always  connected  to  earth  and  standing  with  its  walls  3  cm.  from  the  stem, 
the  potential  gradient  is  100  volts  per  cm.,  and  sufficient  for  most  purposes. 

It  is  not  always  convenient  to  use  a  battery  for  charging  the  electro- 
scope, and  the  device  shown  in  Fig.  227  may  often  serve  instead.    It  is  a 


Fig.  227. — Friction  device  for  charging  electroscopes. 

miniature  frictional  machine,  and  produces  its  charge  of  electricity  by  the 
action  of  depressing  the  plunger,  1,  to  which  two  small  flannel  rubbers,  2  2, 
are  attached.  The  close  contact  of  these  as  they  slide  up  the  celluloid  rod, 
3,  electrifies  it  negatively,  the  charge  being  taken  off  at  the  aluminium 
point,  4,  as  the  rubbers  return  to  their  initial  position,  and  are  auto- 
matically connected  to  a  metal  block,  5,  previously  earthed  by  contact  with 
the  spring,  6.  An  instrument  of  this  kind  is  in  very  general  use  in  a 
radio-physics  laboratory  because  of  its  compactness  and  rehability. 

Units. — For  the  measurement  of  radium  salts  it  is  sufficient  to  express 
the  result  in  terms  of  units  of  weight.  But  in  the  case  of  emanation, 
since  the  actual  quantities  are  so  small,  it  has  been  decided  by  international 
agreement  to  estabhsh  a  new  unit. 

We  have  explained  what  is  meant  by  the  equilibrium  value  of  the 
emanation.  The  new  unit  is  based  on  this  principle  and  is  appropriately 
named  after  Professor  and  Madame  Curie.  The  amount  of  radium  emana- 
tion in  equilibrium  with  1  gramme  of  radium  element  is  called  1  curie.  From 
this  the  milli-curie  and  micro-curie  follow  naturally.  But  in  the  case  of 
certain  natural  "  radioactive  waters,"  where  the  quantities  of  emanation 


PHYSIOLOGICAL  ACTION  343 

are  extremely  small,  another  plan  is  followed  upon  the  continent.  Pro- 
fessor Mache  has  suggested  that,  if  the  saturation  current  produced  by 
the  emanation  from  1  litre  of  water  amomits  to  1  electrostatic  unit  of 
electricity  per  second  in  a  standardised  apparatus,  the  quantity  of  emana- 
tion present  shall  be  called  1000  units.  The  initiation  of  a  new  unit  in 
science  certainly  calls  for  courage  in  these  days,  when  such  long  hsts  of 
them  already  fill  the  books  of  reference.  It  is  in  any  case  desirable  to  be 
able  to  express  readily  the  value  of  one  unit  in  terms  of  another,  and  to 
adhere  as  far  as  possible  to  the  C.G.S.  system. 

To  base  any  system  of  measurement  upon  the  arbitrary  choice  of  a 
special  apparatus  will  appear  to  many  to  have  its  drawbacks,  and  it  is  still 
questionable  whether  it  would  not  be  more  advantageous  on  the  whole 
to  adopt  the  curie  and  its  fractions  for  the  complete  range  of  emanation 
measurement. 

Some  confusion  appears  to  have  crept  into  the  interpretation  of  the 
relationship  between  the  curie  and  the  mache  unit  of  emanation.  One 
authority  tells  us  that  1  curie =3,000,000  mache  units,  while  another  gives 
it  as  being  equal  to  about  2,000,000  mache  units.  Taking  Professor  Mache's 
own  value  of  3-7  x  10 ~^°  curie,  the  correct  relationship  is  1  milU-curie= 
2,702,702-7  M.Es.  or  2-7  milHon  mache  units. 

The  usual  strength  to  prepare  radium  emanation  water  for  internal  use 
is  1  milli-curie  per  litre,  but  water  containing  6  milli-curies  per  Htre  has 
been  used  in  certain  cases.  The  final  products  of  radium,  viz.  KaD,  KaE^, 
RaEg,  and  RaP,  are  of  little  or  no  use  therapeutically,  and  so  they  need  not 
be  referred  to  here. 

It  will  be  remembered,  however,  that  at  the  outset  we  expressed  the 
opinion  that  Alpha  rays  would  be  employed  to  a  greater  extent  if  only  some 
effective  way  of  introducing  them  into  a  tissue  could  be  devised.  The 
subcutaneous  injection  of  substances  holding  the  emanation,  such  as  refined 
petroleum,  appears  to  be  the  most  hopeful.  Great  care  must,  however, 
be  taken  to  employ  it  only  in  very  small  doses.  A  diffusion  apphcator 
has  also  been  devised  by  which  radium  emanation  is  allowed  to  pass 
into  the  tissue,  either  by  absorption  through  the  skin  or  by  a  process  of 
imbedding.  But  so  far  all  methods  of  using  Alpha  rays  are  in  a  highly 
experimental  stage. 

Physiological  Action 

We  have  already  pointed  out  that  the  action  of  a  radiation  may  so  far 
disturb  the  normal  arrangement  of  the  constituents  of  atoms  that  while  the 
influence  lasts  their  usual  properties  are  modified.  Now  there  is  no  doubt 
that  those  who  have  to  do  with  the  application  of  radiations  for  medical  use 
are  beginning  to  feel  more  and  more  acutely  the  need  of  some  working  hypo- 
thesis which  will  guide  their  efforts  and  lead  to  the  accumulation  of  evidence 
along  definite  lines.  The  practical  utility  of  the  far-reaching  discovery  of 
radioactivity  is  certainly  held  in  check  at  the  moment  for  want  of  some 
systematic  attempt  to  Avork  in  accordance  with  a  scheme.  , 


344  EADIATION  THERAPEUTICS 

The  cells  of  organic  bodies  consist  of  complex  molecular  aggregates, 
whose  ultimate  constituents,  as  far  as  we  know,  are  the  electrified  bodies  that 
build  up  their  atoms.  We  know,  further,  that  when  a  suitable  radiation 
falls  upon  these  bodies  there  will  be  an  absorption  of  energy  and  an  exchange 
of  electrons. 

It  is,  therefore,  by  action  upon  the  atoms  themselves  that  the  radiation 
primarily  exerts  its  influence.  By  disturbing  the  bonds  which  hold  together 
the  intramolecular  groups  however,  chemical  changes  will  also  result.  Many 
physiological  actions  of  the  rays  seem  to  be  out  of  all  proportion  to  the  energy 
conveyed  to  the  tissues,  and  moreover,  a  change  once  begun  appears  to 
continue  for  weeks  after  the  cessation  of  the  radiation.  The  action  is  more 
pronounced,  too,  in  the  case  of  immature  and  rapidly-gromng  cells  than  in 
others.  We  suggest  that  the  chief  cause  for  these  effects  is  the  temporary 
suspension  of  the  normal  function  of  the  cells  during  the  time  of  radiation, 
and  that  if  the  radiation  is  not  intense  enough  to  bring  this  about,  it  may, 
nevertheless,  serve  to  produce,  by  physico-chemical  change,  a  product  which 
stimulates  the  growth  of  the  very  cell  we  desire  to  kill  (as  well  as  possibly 
that  of  normal  tissue). 

According  to  this  view,  then,  there  are  two  distinct  actions,  viz.  the 
suppression  of  the  normal  function  of  the  cells,  due  possibly  to  the  ionisation 
of  the  nuclei,  and  the  indirect  effect  of  the  secretion  of  a  product,  in 
the  nature  of  an  anti-body,  which  tends  to  stimulate  growth  against  the 
irritating  presence  of  the  radiation.  If,  in  the  case  of  a  malignant  growth, 
the  former  can  be  maintained  for  a  sufficiently  long  time,  the  cells  die  from 
want  of  their  normal  functions,  and  even  the  production  of  the  anti-body  in 
excess  is  harmless,  or  even  beneficial,  if  it  stimulate  the  normal  cells  to 
proliferate.  The  dead  cells  are  then  slowly  absorbed,  while  the  normal  tissue 
takes  its  place. 

With  the  accumulation  of  careful  observation  at  our  disposal,  the  time 
cannot  be  far  distant  when  a  broad  generalisation  will  become  possible,,  and 
the  medical  use  of  radiations  thereby  greatly  extended.  The  comparison 
of  the  action  of  rays  upon  nucleated  and  non-nucleated  cells,  the  possibility 
of  producing  immunisation  by  radiations,  and  many  other  experiments, 
should  ultimately  give  important  results,  and  lead  to  still  wider  use  for 
radioactive  substances  in  the  cure  or  alleviation  of  disease. 

C.  E.  S.  P. 


THE   PRACTICAL   APPLICATION   OF   RADIUM 
TO   DISEASE 

In  this  section  of  the  book  it  will  be  sufficient  to  mention  the  conditions 
where  radium  has  been  found  to  possess  advantages  over  X-rays  or  other 
forms  of  treatment. 

It  should  be  stated  at  the  outset  that  radium  will  produce  effects  in  all 
the  conditions  in  which  X-rays  are  used,  the  effect  being  due  to  the  action 
of  radiations  from  whatever  source  they  are  produced.  In  the  following 
pages  a  number  of  conditions  will  be  described  where  radium  has  undoubted 
advantages  over  any  other  form  of  treatment.  When  this  is  not  the  case, 
radium  should  not  be  employed  as  long  as  the  price  of  this  element  is  so 
prohibitive  as  it  now  is.  When  the  two  agents  are  of  equal  therapeutic 
value,  another  factor  sometimes  influences  the  choice,  namely,  the  ease  with 
which  one  or  the  other  may  be  applied. 

The  chief  points  which  influence  the  choice  of  radium  in  therapeutics 
are  : 

(1)  The  greater  penetration  of  the  Beta  and  Gamma  rays,  more  particu- 
larly the  latter. 

(2)  The  convenience  with  which  radium  may  be  applied  to  several  of 
the  internal  organs. 

(3)  The  ease  with  which  it  can  be  appHed  to  the  interior  of  a  tumour 
mass,  in  cases  where  it  would  be  very  difficult  for  X-rays  to  produce  the  same 
therapeutic  eflect  without  great  destruction  of  tissue. 

(4)  The  fact  that  when  dealing  with  highly  nervous  patients  the  apphca- 
tion  is  not  nearly  so  alarming  as  that  of  X-rays. 

(5)  The  fact  that  patients  may  not  be  in  a  condition  to  be  moved  to 
an  X-ray  department. 


Methods  of  using  Radium 

Radium  therapy  has  been  practised  for  several  years,  and  during  that 
time  the  methods  of  application  have  been  gradually  improved.  At  first 
its  use  was  confined  to  external  applications,  and  these  still  hold  an 
important  place  in  treatment ;  the  radium  was  frequently  of  unknown 
strength,  and  also  often  in  percentages  much  under  the  stated  activity. 

345 


346  KADIATION  THEEAPEUTICS 

More  accurate  measurements  and  a  higher  percentage  of  purity  of  the 
radium  salts  have  led  to  a  great  improvement  in  the  technique  of  radium 
therapy. 

The  equipment  of  a  radium  laboratory  should  first  be  briefly  con- 
sidered, as  this  is  the  centre  from  which  all  treatment  must  emanate  if  it  is 
expected  to  be  on  the  right  scientific  lines. 

Assuming  that  we  have  at  our  disposal  a  certain  quantity  of  radium, 
how  is  it  going  to  be  used  to  the  best  advantage  ?  The  answer  is  largely 
governed  by  the  type  of  cases  to  be  treated. 

The  chapter  on  physics  will  have  acquainted  the  reader  with  the  active 
properties  of  radium.  The  agent  is  constantly  giving  off  a  gas,  the  emana- 
tion, which  possesses  the  active  properties  of  radium,  the  only  difference 
being  that  the  decay  curve  of  the  emanation  is  fairly  rapid  (see  curve,  p.  335, 
in  section  on  physics  of  radium). 

Bearing  in  mind  this  decay  and  its  time  factor,  it  is  possible  to  utilise 
the  emanation  in  therapeutics  in  a  variety  of  ways  which  will  be  presently 
described.  For  all  practical  purposes  the  emanation  may  take  the  place 
of  the  radium  in  metal  tubes  now  so  frequently  used.  In  order  to  obtain 
the  maximum  value  from  the  supply  of  radium,  it  is  obvious  that  a  portion 
at  least  of  the  salt  should  be  kept  in  solution  in  order  that  there  may  be  a 
constant  supply  of  emanation  at  stated  intervals. 

The  method  of  drawing  off  the  emanation,  already  described,  may  be 
utilised  in  therapeutics.  The  emanation  may  be  used  in  the  following 
ways  : 

1.  As  an  inhalation,  alone  or  combined  with  oxygen.  Great  claims 
are  made  in  favour  of  this  method,  especially  in  Germany,  where  regular 
inhalation  institutes  are  in  full  work.  It  is  most  important  when  using 
any  of  the  complicated  machines  now  employed,  to  ascertain  that  they 
actually  do  contain  radium  in  a  proportion  strong  enough  to  exercise  a 
therapeutic  effect.  There  can  be  no  doubt  that  this  means  of  using  the 
inhalation  is  valuable,  but  careful  calculations  must  be  made  in  order  to  get 
a  percentage  of  emanation  of  sufficient  strength  to  be  of  use.  The  action 
of  radium  emanation  by  inhalation  is  primarily  upon  the  lungs,  and  if  care 
is  not  exercised  an  injurious  effect  may  be  produced.  The  emanation  is 
absorbed  and  finds  its  way  into  the  blood,  by  which  it  is  circulated  freely 
throughout  the  body.  Its  action  may  therefore  be  far-reaching,  and  possibly 
a  great  field  of  usefulness  exists  in  the  future  for  this  method. 

It  is  claimed  that  the  beneficial  effects  produced  by  radium  water  baths 
are  obtained  through  the  respiratory  organs,  the  emanation  given  off  from 
the  radium  in  the  bath  being  inhaled  by  the  patient ;  it  is  quite  likely  that 
this  explanation  is  a  correct  one,  for  it  is  difficult  to  imagine  any  action 
taking  place  by  way  of  the  skin  surface. 

2.  The  emanation  may  be  forced  into  water,  and  the  patient  be 
given  a  stated  dose  of  this  at  regular  times. 

Here,  again,  a  large  margin  of  error  must  be  allowed  for,  because  the 
emanation  slowly  decays,  so  that  if  it  is  not  at  full  strength  when  the  water 


METHODS  OF  USING  RADIUM 


347 


is  first  dispensed  it  will  be  practically  valueless  in  less  than  a  week  ;  water 
impregnated  with  emanation  of  radium  must,  therefore,  be  given  at  first 
only  in  small  quantities  at  stated  times,  and  in  gradually  increasing 
quantity  in  order  to  compensate  for  the  gradual  loss  of  activity,  which  is 
the  result  of  the  decay  of  the  emanation. 

The  emanation  is  absorbed  by  oil,  water,  and  other  hquids  in  definite 
relative  proportions,  and  any  of  these  may  be  used  as  a  means  of  getting  the 
emanations  into  the  system,  or  it  may  be  injected  into  the  substance  of  or 
around  a  growth. 

3.  The  gas  may  be  passed  into  glass  or  metal  tubes,  or  flat  g'as-tig'ht 


ttk'.- 


Fig.  228. — Apparatus  for  inhalation  of  radium  emanation  and  oxygen.     (Radium,  Limited.) 


applicators  may  be  made  to  receive  the  emanation  under  pressure.  These 
may  be  employed  in  exactly  the  same  way  as  the  radium  tube,  bearing  always 
in  mind  the  decay  curve  of  the  emanation.  Tubes  containing  emanation 
may  be  inserted  into  a  tumour  mass,  and  left  for  days  if  desirable. 

4.  By  using  a  special  electrical  device  the  emanation  can  be  deposited 
upon  metal  points  or  flat  surfaces  of  metal ;  these  deposits  retain  the  same 
activity  as  the  purest  radium,  but  the  duration  of  the  activity  is  much  less 
than  that  of  the  emanation  itself.     The  deposit  of  radioactive  bodies  on 


348 


RADIATION  THERAPEUTICS 


flat  applicators  may  be  used  in  many  ways,  as,  for  instance,  for  ionisation, 
a  powerful  galvanic  current  being  employed  to  drive  them  into  the  tissue. 
Haret  reports  a  number  of  cases  which  have  received  great  benefit  by  this 
method  of  treatment. 

Of  the  many  methods  of  using  radium  emanation,  the  one  which  com- 
mends itself  most  forcibly  is  that  by  which  the  emanation  is  placed  in  re- 
ceptacles, which  can  be  used  in  a 
great  variety  of  ways  according  to 
the  particular  case  requiring  treat- 
ment. The  other  methods  will  be  re- 
ferred to  again  in  the  section  dealing 
with  the  treatment  of  particular 
diseases.  By  using  a  large  quantity 
of  radium  salt  in  solution  and  draw- 
ing off  the  emanation,  it  is  possible 
to  treat  a  large  number  of  patients 
by  means  of  specially  designed 
tubes,  which  can  be  constructed  to 
suit  each  particular  case.  Patients 
at  a  distance  may  receive  treat- 
ment by  means  of  these  applicators, 
and  patients  at  hospitals  may  be 
allowed  to  go  home  with  the  radium 
emanation  applicator,  an  advan- 
tage which  is  not  possible  when 
using  the  actual  radium,  on  account 
of  its  financial  value. 

5.  By  means   of    a    liquid-air 
plant,  the  emanation  can  be  forced 
into  small  platinum  tubes,  which  may  be  inserted  into  the  substance  of 
a  tumour. 

The  parent  radium  does  not  depreciate  at  all  noticeably,  and  is  ready  to 
yield  up  its  growth  of  emanation  at  stated  intervals,  200  to  500  mgrms.  of 
radium  in  solution  yielding  emanation  in  sufficient  quantity  to  treat  a  large 
number  of  patients. 

The  additional  advantage  of  being  able  to  make  a  special  applicator  for 
the  treatment  of  each  case  is  of  great  importance.  The  applicator  may  be 
of  a  suitable  shape  to  allow  of  the  maximum  effect  being  obtained,  and  being 
of  glass  or  cheap  metal  may  be  destroyed  after  each  apphcation. 

It  is  in  the  treatment  of  out-patients  that  this  method  is  found  useful. 
The  apphcator  is  placed  in  position,  and  the  patient  given  definite  instruc- 
tions as  to  the  time  at  which  he  should  remove  it. 

6.  The  Radium  Salts. — This,  up  to  the  present,  is  the  manner  in 
which  radium  has  been  most  frequently  or  most  generally  employed.  It 
will  be  necessary  to  go  into  the  preparation  of  these  applicators  at  some 
length,  for  it  is  on  a  correct  assessment  of  the  activity  of  these  apphcators 


Fig.  229. 


-Glass  applicators  for  radium 
emanation. 


RADIUM  SALTS  349 

and  the  quantity  of  the  radium  they  contain  that  successful  treatment   is 
based. 

Bearing  in  mind  the  great  value  of  radium  at  present  market  prices, 
it  is  obvious  that  no  clinique  can  afford  to  run  great  risks  of  loss  of  radium 
by  faulty  apphcators.  The  French  method  of  putting  radium  upon  linen 
to  form  toiles  is  useful  and  easy  of  application,  but  as  these  toiles  cannot 
be  regarded  as  in  any  degree  antiseptic  or  aseptic,  they  consequently 
cannot  be  used  in  cases  where  care  in  this  respect  is  necessary.  The  most 
useful  form  of  applicator  for  superficial  conditions  is  the  flat  one,  which  may 
be  of  any  desired  size  and  shape.  Figures  are  shown  to  illustrate  radium 
applicators,  the  radium  being  incorporated  in  a  varnish  and  spread  over  the 
metal  surface  of  the  apphcator  (see  Figs.  238  and  239).  The  dimensions 
most  frequently  employed  for  these  forms  of  applicators  are  : 

Square  applicators  :  2,  3,  and  4  cm.  square. 
Oblong  applicators  :  2  cm.  x  3  cm.  ;  3  cm.  x  4  cm. 

The  amount  of  radium  salt  used  is  generally  1  centigramme  per  square 
centimetre.  The  activity  of  the  radium  salt  must  also  be  taken  into  account. 
As  the  strength  may  vary  from  10,000  to  2,000,000  activity,  it  is  obvious  that 
mdely  diversified  effects  will  be  obtained  by  using  the  apphcator  charged 
with  salts  at  any  of  the  gradations  between  these  two  Hmits. 

A  convenient  form  of  flat  applicator  is  illustrated  in  Fig.  231. 

The  special  varnish  employed  in  the  manufacture  of  apphcators  A^ith 
fixed  salts  is  made  to  resist  various  physical  and  chemical  actions  for  periods 
more  or  less  long  ;  it  may  be  subjected  without  damage  to  a  temperature  of 
300°  C.  or  thereabouts  ;  it  resists  the  action  of  the  following  cold  or  hot 
liquids  and  solutions  for  long  or  short  periods  :  water,  permanganate  of 
potassium  of  1  per  cent,  oxygenised  water  of  12  volumes,  bisulphate 
of  soda  of  1  per  cent,  glycerine,  vaseline,  bichloride  of  mercury  of  1  per  cent. 

The  use  of  absolute  or  90  per  cent  alcohol,  or  of  ether,  must  be  avoided  ; 
but  a  short  application  of  cold  alcohol  does  not  appear  to  have  any  very 
serious  results. 

Screens  of  nickel,  aluminium,  lead,  silver,  or  platinum  may  be  employed. 

Tubes  with  Free  Salts  of  Radium.— A  salt  of  radium,  by  choice  the 
sulphate,  is  enclosed  in  a  platinum  tube,  the  walls  of  which  are  of  a  known 
thickness,  generally  tV  of  a  milhmetre,  the  external  diameter  of  the  tube 
being  at  least  2  miUimetres.  The  length  and  the  diameter  vary  in  accordance 
with  the  quantity  of  the  salt  contained  in  the  tube.  For  instance,  a  tube 
containing  1  centigramme  of  salts  of  radium  may  have  an  exterior  diameter 
of  2  millimetres  and  a  total  length  of  18  millimetres.  Tubes  used  more 
recently  are  much  less  in  diameter.  These  narrow  tubes  are  very  useful  for 
insertion  into  the  substance  of  a  growth. 

The  length  of  the  tube  is  determined  by  the  diameter  and  the  smallest 
space  the  radium  can  be  packed  into. 

The  object  of  the  thick  silver  screen  at  the  back  shown  in  Fig.  232  is  to 
protect  the  skin  surface  not  receiving  treatment.     This  is  used  in  situations, 


350 


RADIATION  THERAPEUTICS 


such  as  the  axilla,  where  the  skin  on  the  inner  side  of  the  area  comes  in 

contact  with  the  applicator. 

A  tube  may  have  an  outer  case  (acting  as 
a  screen)  fitted  to  it  with  a  screw  cap.  The 
screw  is  provided  in  order  that  the  applicator 
may  have  a  length  of  silver  wire  joined  up  to 
it  for  applications  in  the  oesophagus. 

In  some  instances  a  pointed  screw  terminal 
is  added  to  the  distal  end  to  facilitate  the 
introduction  of  the  tube  into  a  growth.  When 
using  this  applicator  for  insertion  into  the 
substance  of  a  growth,  it  is  only  necessary  to 
use  a  local  anaesthetic. 

The  radium  in  a  metal  tube  is  the  most  useful 
form  in  which  it  is  employed  and  it  is  capable  of 
being  used  for  application  : 

(1)  Externally. 

(2)  To  the  interior  of  the  bpdy  in  such  situa- 
tions as  the  mouth,  nose,  throat,  oesophagus, 
rectum,  vagina,  etc. 

(3)  Into  the  substance  of  a  tumour  by  making 
incisions,  and  inserting  the  radium  tubes  into  the 
centre  of  the  mass. 

The  special  methods  of  preparation  of  these 
be  described  in  the  section  devoted  to   treatment   of 


Fig.  230. —The  length  of  the 
tube  is  determined  by  the  dia- 
meter and  the  smallest  space 
the  radium  can  be  packed  into. 

A,  Outer  tube. 

B,  Space  containing  radium. 


radium  tubes  will 

diseases  suitable  for  radium  therapy. 


Filtration  of  Radium  Rays 

The  effects  produced  by  a  radium  appHcation  depend  upon  the  quantity 
of  radium  used,  its  strength,  and  the  duration  of  the  exposure.  The  effect 
is  further  influenced  by  the  presence  or  absence  of  a  filter. 

These  filters  are  most  important,  and  a  number  should  always  be  at 
hand.  For  the  flat  appHcators  it  is  necessary  to  have  filters  from  t  o  of  a 
millimetre  to  2  mm.,  according  to  the  result  we  desire  to  obtain.  Using 
20  mgrms.  of  a  radium  salt  of  500,000  activity  on  an  appUcator  2  cm. 
square,  a  marked  reaction  may  be  produced  on  the  skin  by  one  hour's  ex- 
posure. (A  thin  sheet  of  rubber  or  gutta-percha  tissue  should  always  be 
used  to  protect  the  radium.)  A  half  mm.  of  aluminium  acting  as  a  screen 
will  delay  the  appearance  of  the  reaction  ;  therefore,  to  get  a  similar  degree 
of  reaction  the  exposure  would  require  to  be  longer.  When  the  activity  of 
the  radium  is  greater  the  effect  will  be  proportionately  increased. 

The  metallic  tubes  containing  free  radium  require  to  be  used  with  screens 
of  known  thickness,  which  may  be  larger  tubes  of  silver  or  platinum,  of  a 
thickness  of  one  to  two  miUimetres  of  platinum  or  two  to  four  mm.  of  silver. 
When  these  tubes  are  not  available  an  efl&cient  filter  may  be  made  by 


FILTRATION  OF  RADIUM  RAYS 


351 


rolling  a  portion  of  sheet  lead  around  the  platinum  tube  containing  the 
radium.      Silver  and  lead  have  equal  powers  of  obstructing  the  passage  of 


Fi(5.  231.— Flat 
metal  applica- 
tor. Radium  is 
packed  in  area 
represented  by 
dotted  lines. 


Fig.  232.  — Showing  method  of  arrang- 
ing tubes  with  filters. 

A  thicli  silver  screen  with  grooves  to 
take  two  radium  tubes.  In  front  is  a 
groove  for  platinum  filters.  Ten  of 
these  may  be  used  ;  each  is  ^  mm. 
thick.  The  holder  has  a  thick  backing 
of  1  cm.  silver,  to  protect  the  adjacent 
skin  surface  from  the  rays  when  in  use. 


Fig.  233.  —  Silver 
screen  1  mm.  thick 
adapted  to  contain 
two  tubes  side  by 
side  and  fitted 
with  screw  ter- 
minal. 


the   rays    from  the   radium,  platinum    possessing    twice   the 
absorption  value  of  lead  or  silver. 

The  thickness  of  the  filter  to  be 
employed  is  estimated  beforehand 
according  to  the  effect  desired,  the 
quantity  of  the  radium  employed, 
and  the  tissues  to  be  treated. 

Secondary  Radiations  from  Tubes 
containing  Radium. — It  is  not  sufl&- 
cient  simply  to  use  a  filter  for  the 
absorption  of  the  radium  rays.  It 
must  be  borne  in  mind  that  the 
filters  also  give  off  rays  which  are         .      ,.  .^     ,. 

known     as    secondary     radiations ;         ^•i^  ^^^ 

these  are  injurious  to  the  tissues 
with  which  they  come  in  contact, 
and  must  therefore  be  filtered  if 
damage  to  the  tissues  is  to  be  pre- 
vented. Rubber  tubing  of  a  thick- 
ness of  I  to  4  mm.  is  sufficient  for 
this  purpose. 


Fig.  234. — Radium  in  a 
fiat  metal  tube  show- 
ing, by  dotted  lines, 
area  of  active  service. 

Two  forms  of  terminal 
ai'e  shown :  (1)  Screw 
top  fitted  to  a  length  of 
silver  wire  ;  (2)  screw 
top  perforated  for  silk 
thread  or  fine  silver  wire. 


Silk  suture 


Rubber 


Radium 
tube 


\J 


Fig.  235.  —  Radium 
tube  contained  in 
rubber  tubing. 


352  EADIATION  THERAPEUTICS 

The  Influence  of  Air-space  in  Filtration  of  Radium  Rays. — The  distance 
of  the  radium  from  the  surface  of  the  body  also  prevents'the  injurious  effects, 
in  other  words,  air  space  acts  as  a  filter  by  preventing  radiations  of  a 
particular  length  from  reaching  the  surface.  In  long  exposures  twenty  or 
thirty  layers  of  hnt  should  be  interposed  between  the  radium  tubes  and  the 
surface  of  the  body. 


Radium  Tubes  in  the  Substance  of  a  Tumour 

Attention  must  be  paid  to  the  follo\\ing  points  : 

(a)  The  tabe  must  be  surrounded  by  the  growth. 

(b)  When  more  than  one  tube  is  used,  the  tubes  should  be  at  equal 
distances,  so  that  an  equal  action  be  obtained  throughout  the  growth. 

(c)  The  radium  tube  inside  its  filter  must  be  enclosed  in  rubber  tubing 
and  closed  at  each  end. 

The  tube  containing  the  radium  must  not  be  subjected  to  great  heat. 
It  must  therefore  not  be  sterilised  by  heat.  It  may,  however,  be  placed  in  a 
solution  of  carbolic  acid  for  a  short  time  before  use.  The  outer  filter  may  be 
boiled,  and  rubber  tubing  should  be  sterihsed  before  use.  It  is  important 
that  these  measures  should  be  carried  out  prior  to  the  insertion  of  the  radium 
tube  into  the  substance  of  a  growth. 


Treatment  of  Deep-seated  Tumours  by  external 
Applications 

When  treating  deep-seated  tumours  it  is  often  necessary  to  give  several 
exposures  to  the  exterior  of  the  growth,  in  such  a  manner  that  a  fairly  equal 
dose  is  given  all  over  the  surface  of  the  mass.  If  a  large  quantity  of  radium 
is  available  this  could  be  done  by  one  application  ;  but  the  majority  of 
operators  have  only  a  very  limited  supply  at  their  disposal,  and  in  such  cases 
it  is  necessary  to  give  several  exposures  to  cover  the  surface.  The  following 
method  \\dll  be  found  useful,  a  malignant  enlargement  of  the  thyroid  requiring 
treatment  being  taken  as  an  illustration,  and  200  mgrms.  of  radium  sulphate 
in  three  tubes  being  available. 

The  surface  of  the  tumour  is  mapped  out  mth  a  skin  pencil,  each  section 
being  numbered.  A  piece  of  lead  1  cm.  thick  is  moulded  to  the  surface 
of  the  tumour,  windows  being  cut  out  in  this  corresponding  to  the  areas 
already  marked.  The  radium  is  arranged  on  the  filter  to  be  employed,, 
say  3  mm.  of  lead,  this  cutting  out  practically  all  of  the  Beta  rays. 

The  filter  is  fixed  over  the  window  above  the  area  to  be  treated.  The 
tubes  are  attached  to  the  surface  of  the  filter  by  adhesive  plaster. 

The  tubes  are  so  arranged  that  the  maximum  of  the  radiations  go  through 
the  centre  of  the  filter.  The  tubes  are  enclosed  in  rubber  tubing,  and  thirty 
layers  of  lint  are  placed  under  the  thick  lead  which  has  been  moulded  to  the 
surface  of  the  tumour.     Each  area  receives  a  portion  of  radiation  from  the 


DOSAGE  IN  RADIUM  THERAPY  353 

exposure  of  the  adjoining  one  ;.  -the  maximum  of  each  area  is  obtained  with 
the  radium  directly  over  its  centre,  but  each  periphery  gets  nearly  a  half 
from  the  exposure  of  the  adjoining  area.  Thus  a  certain  degree  of  overlapping 
must  occur,  but  if  the  exposures  are  arranged  as  above,  each  area  should 
have  a  centre  of  maximum  radiation,  and  the  periphery  of  each  receives 
approximately  a  full  dose  from  the  two  adjoining  applications.  In  this  way 
it  is  possible  to  get  the  maximum  of  exposure  all  over  the  surface  of  a  tumour 
with  a  fair  degree  of  certainty. 

Using  200  mgrms.  of  radium,  and  dividing  the  tumour  into,  say  10  areas, 
and  giving  twenty-four  hours'  exposure  to  each,  it  is  possible  to  administer 
a  relatively  large  dose,  amounting  in  all  to  24  x  10  x  200=48,000  mgrm.- 
hours.     The  exposure  of  the  whole  tumour  would  take  ten  days. 

There  are  several  cautions  to  be  observed  when  treating  with  large 
quantities  of  radium. 

1.  The  effect  of  the  earlier  exposures  should  be  carefully  watched, 
because  if  a  marked  reaction  should  come  on  rapidly  the  subsequent  ex- 
posures should  be  postponed. 

2.  Short  of  a  severe  reaction  in  serious  cases  the  treatment  should  be 
persisted  in.  The  beneficial  effect  may  be  secured  if  an  adequate  dose  is 
given,  with  practically  no  skin  reaction,  but  the  appearance  of  a  slight 
reaction  is  an  indication  that  the  maximum  skin  dose  has  been  given.  An 
interval  of  time  should  be  allowed  to  elapse  before  repeating  the  exposure 
over  the  same  area.  This  should  not,  however,  prevent  the  treatment  from 
being  carried  on  over  other  areas  in  the  proximity. 


DOSAGE  IN  RADIUM  THERAPY 

The  most  difficult  question  in  radium  treatment  is  that  of  dosage. 
There  are  many  points  which  require  to  be  considered. 

The  activity  of  salts  of  radium  is  evidenced  by  the  photographic, 
chemical,  electrical,  and  physiological  effect  of  its  radiation.  Thus,  if  one 
salt  is  more  active  than  another,  it  has  a  stronger  effect  upon  the  substance  or 
tissue  with  which  it  is  brought  in  contact ;  if,  for  example,  a  photographic 
plate  is  used,  the  action  will  vary  immensely  with  the  strength  and  quantity 
of  radium  used.  Pure  salts  of  radium,  dried  and  prepared  for  several 
months,  have  a  constant  radiation,  by  which  they  are  always  identified, 
and  the  number  of  rays  produced  by  a  quantity  of  pure  radium  salt  are 
actually  proportional  to  its  weight.  Generally  speaking,  for  equal  weight, 
the  salt  which  is  the  richest  in  radium  will  have  the  most  intense  radiation, 
and  its  value  can  be  expressed  in  salts  of  pure  radium. 

Unit  of  Radiation. — For  the  time  being  the  measure  which  was  intro- 
duced early  in  the  history  of  radium  therapy  has  been  maintained.  Instead 
of  measuring  the  value  in  pure  salts  of  radium,  it  is  compared  with  the 
standard  of  activity. 

Standard    of   Activity. — In   France   and   other   countries   metallic 

23 


354 


EADIATION  THEKAPEUTICS 


uranium  is  taken  as  the  standard.  Equal  weights  of  radioactive  salts  and 
metallic  uranium,  or  the  corresponding  quantity  of  uranium  oxide  spread 
on  the  same  surface,  are  compared.  The  radiation  of  uranium  is  taken  as 
unity,  when  the  activity  of  the  pure  bromide  of  radium  is  equal  to  about 
2,000,000  times  that  of  an  equal  weight  of  uranium. 


Relation  between  the  Value  of  Radium  and  its  Activity 

As  an  example,  a  table  is  appended  of  a  few  values  of  pure  salts  of  radium 
and  their  corresponding  activities  : 


Value  of  Pure 
Bromide  of  Radium. 

Activity. 

Value  of  Pure 
Bromide  of  Radium. 

Activity. 

Per  cent. 
0-0025 
0-005 
0-025 
0-05 
0-25 
0-5 

50 

100 

500 

1,000 

5,000 

10,000 

Per  cent. 
1 

2-5 

5 

25 

50 

100 

20,000 

50,000 

100,000 

500,000 

1,000,000 

2,000,000 

The  percentage  of  pure  radium  salt  in  a  particular  quantity  of  a  mixture 
of  salt  and  inert  matter  determines  the  activity  of  the  particular  preparation. 
When  several  radium  preparations  are  in  use,  it  is  well  to  test  one  tube,  of  say 
50  mgrms.,  and  having  ascertained  its  percentage  of  activity,  to  regard  it 
as  the  standard  by  which  the  other  preparations  are  estimated.  The  activity 
of  the  radium  is  estimated  by  means  of  the  electroscope,  and  it  is  customary 
to  base  the  calculations  on  the  Gamma  ray  effect  upon  the  gold  leaf  of  the 
electroscope.  For  this  purpose  it  is  necessary  to  absorb  all  the  Beta  rays 
before  the  Gamma  rays  can  be  dealt  with.  This  is  easily  done  by  inter- 
posing a  layer  of  lead  1  cm.  thick  between  the  electroscope  and  the  tube  of 
radium.  Placing  the  radium  at  a  given  distance,  the  rate  of  fall  of  the  gold 
leaf  is  watched  and  timed.  Another  and  stronger  tube  is  then  placed  on 
exactly  the  same  spot  as  the  first  tube.  The  reading  of  the  scale  indicating 
the  fall  of  the  leaf  is  again  taken,  and  it  is  a  matter  of  calculation  to  estimate 
the  activity  of  the  second  tube  of  radium. 

When  it  is  necessary  to  estimate  the  activity  of  emanation,  an  emanation 
electroscope  must  be  employed.  This  is  also  useful  when  deahng  Avith  sub- 
stances and  fluids  which  have  become  radioactive,  such  as  water,  urine,  etc. 

Ag'e  of  the  Salts. — Immediately  they  have  been  prepared,  salts  of 
radium  give  out  only  a  slight  radiation,  which  consists  entirely  of  the  Alpha 
rays,  the  radiation  increasing  gradually,  until  its  maximum  constant  value 
is  attained  at  the  end  of  one  or  two  months.  This  is  a  point  which  should 
always  be  kept  in  view  when  dealing  with  salts  of  radium  which  have  been 
freshly  prepared.  These  preparations  may  be  used,  but  the  calculation  of  the 
dosage  must  be  carried  out  for  each  preparation.  It  is  useless  to  compare  these 
preparations  with  matured  ones,  from  the  point  of  view  of  therapeutic  effect. 


RADIUM  AND  ITS  ACTIVITY  355 

Variation  of  Activity. — If  salts  of  radium  are  enclosed  in  carefully- 
sealed  receptacles,  they  attain  a  radiation  which  always  remains  constant. 
Various  causes,  however,  may  modify  the  constancy  of  radiation  : 

(1)  Exposure  of  the  salts  to  the  atmosphere. 

(2)  Absorption  of  moisture. 

(3)  Dissolution. 

(4)  Increase  of  the  temperature  of  the  atmosphere. 

In  order,  therefore,  to  maintain  a  constant  radiation,  these  several 
factors  must  be  taken  into  account. 

Radium  enclosed  in  metal  tubes  must  be  carefully  sealed  in  order  to 
obtain  the  maximum  effect.  Each  tube  should  be  carefully  tested  to  detect 
any  emanation  leak,  which  may  lower  the  activity  of  the  preparation,  and  in 
practical  therapeutics  lead  to  serious  errors  in  dosage  and  effect  upon  tissues. 

Dosag-e  of  Emanation  in  Solution. — The  solution  most  frequently 
used  is  water,  the  emanation  being  mixed  with  it  in  a  definite  proportion. 
In  mixtures  prepared  in  the  laboratory,  1  milli-curie  to  a  htre  of  water  is  a 
usual  strength.  This  preparation  is  used  for  drinking.  In  special  cases 
the  strength  may  be  greatly  increased. 

If  the  solution  cannot  be  measured  in  electrostatic  imits,  the  testing  of 
small  quantities  of  emanation — as,  for  example,  in  mineral  springs — results 
in  very  small  fractions.  In  order  to  obviate  this,  Professor  Mache  of  Vienna 
proposed  to  multiply  this  fraction  by  1000. 

Mache  Unit. — This  unit  is  so  convenient  that  it  is  made  use  of  at  all 
the  well-known  spas  (where  the  activity  of  the  water  is  very  low),  and  by  many 
specialists  of  radium  therapy  upon  the  Continent,  who  all  use  the  Mache 
unit  for  the  dosage  of  emanation. 

Dosagce  when  using*  Flat  Applicators. — This  will  vary  with  the  tissue 
to  be  treated  and  the  quantity  of  radium  present  in  the  applicator. 

The  physiological  effect  produced  upon  the  tissue  will  become  a  practical 
factor  in  the  calculation  of  the  dose.  It  is  well  to  determine  beforehand 
the  degree  of  actiAdty  by  means  of  the  electroscope,  and  then  to  apply  the 
applicator  for  a  given  time  to  the  surface  of  the  skin  in  a  healthy  subject ; 
or,  for  experimental  purposes,  an  animal  may  be  used.  The  effect  may  take 
some  time  to  appear,  so  the  exposure  must  not  be  repeated  until  time  has 
been  allowed  for  reaction  to  manifest  itself.  Having  ascertained  the  re- 
action time  for  healthy  tissue,  it  is  easy  so  to  regulate  the  exposure  in  diseased 
conditions  as  to  produce  the  degree  of  action  required.  Thus,  in  simple 
conditions  such  as  cheloid,  nsevi,  etc.,  it  is  only  necessary  to  produce  a  mild 
degree  of  reaction,  and  keep  it  up  by  repeated  exposures  at  stated  intervals 
to  get  a  cure,  while  for  rodent  ulcer,  epithelioma  of  the  skin,  etc.,  it  is  some- 
times necessary  to  produce  a  degree  of  necrosis  of  the  tumour  mass  before 
a  beneficial  result  can  be  looked  for. 

Practical  experience  in  the  use  of  these  applicators  is  therefore  a  sine 
qua  non  for  every  radium  therapist. 

Dosag-e  when  the  Free  Radium  is  contained  in  Metal  Tubes. — 
Practically  all  the  effects  produced  by  the  fiat  applicator  may  be  obtained 


356  RADIATION  THEEAPEUTICS 

when  radium  tubes  are  used.  Each  tube  has  a  number  of  filters  fitted  to  it, 
ranging  from  |  mm.  to  3  mm. ;  these  filters  may  be  of  silver,  lead,  or  platinum, 
the  latter  being  the  best,  because  it  has  a  greater  density  than  the  others, 
and  consequently  occupies  less  space.  This  is  very  important  when  tight 
strictures  of  the  oesophagus  or  diseases  of  the  bladder  or  urethra  require 
treatment. 

The  small  tube  in  which  the  radium  is  sealed  is  generally  -f-^  to  y\  of  a 
millimetre  thick,  so  if  superficial  areas  require  treatment,  a  short  exposure 
of  a  half  to  one  hour,  with  the  radium  tube  enclosed  in  a  thin  rubber  one, 
should  sufiice  to  produce  a  mild  degree  of  reaction.  Should  a  deeper  effect  or 
a  surface  effect  free  from  reaction  be  desirable,  then  a  thicker  filter  may  be  em- 
ployed, and  the  exposure  prolonged.  In  all  these  instances  it  is  the  Beta  rays 
(all  but  the  softest)  and  all  the  Gamma  rays  which  are  used.  In  some  chronic 
conditions,  or  in  cases  of  widespread  disease,  it  is  necessary  to  get  deeper 
effects,  and  the  greater  quantity  of  Beta  rays  are  cut  off,  so  that  only  the 
Gamma  rays  are  employed.  In  such  cases  thicker  filters  are  necessary,  2  mm. 
of  platinum  or  4  of  lead  or  silver  cutting  off  practically  all  the  Beta  rays. 
When  using  the  Gamma  rays  entirely,  the  exposure  must  be  greatly 
increased,  because  the  percentage  of  Gamma  rays  given  of!  from  a  quantity 
of  radium  is  very  small  (about  3  per  cent). 

In  order  to  get  a  physiological  effect  upon  the  tissues,  long  exposures 
are  required,  and  these  will  vary  with  the  quantity  of  radium  present  and 
its  distance  from  the  tissue  requiring  treatment.  The  Gamma  ray  effect 
upon  the  skin  is  practically  negligible  when  proper  precautions  are  taken 
within  normal  limits  of  exposure.  Exposures,  with  large  quantities  of  radium 
in  well-filtered  doses,  may  be  given  up  to  twenty-four  hours  without  damag- 
ing the  skin.  In  some  instances,  where  there  is  ulceration  of  the  surface 
of  a  growth,  the  skin  factor  in  exposure  ceases  to  exist,  and  then  much  longer 
exposure  to  the  surface  of  the  growth  can  be  given,  because  this  surface  will 
bear  much  longer  radiation,  and  in  many  instances  it  is  desirable  to  hasten 
the  ulcerative  process.  The  expression  of  the  radium  dose  in  accurate  terms, 
is  a  matter  of  considerable  difficulty. 

We  have  already  dealt  with  the  two  methods  of  expressing  the  dose  in 
the  case  of  emanation,  namely,  the  milli-curie  and  the  Mache  unit. 

Unit  of  Milligram-Hours. — Dawson  Turner  has  introduced  an  ex- 
pression of  dosage  which  is  thoroughly  practical  for  ordinary  use,  with  certain 
reservations.  He  takes  the  quantity  of  radium  used,  and  multiplies  it  by 
the  number  of  hours  representing  the  time  factor  of  exposure.  Thus,  24 
hours  multiplied  by  200  mgrms.  represents  an  exposure  of  4800  mgrm.- 
hours.  This  takes  no  account  of  the  activity  of  the  radium  used,  which  may 
vary  from  500  to  2,000,000  activity,  nor  does  it  take  into  consideration  the 
distance  of  the  applicator  from  the  surface  undergoing  treatment. 

It  would  be  better  to  include  the  activity  (a  note  being  taken  of  it  in 
all  exposures),  the  time  of  exposure  and  the  quantity  of  radium,  the  thickness 
of  the  filter  and  the  distance  from  the  periphery.  Thus  a  record  of  all 
exposures  should  include  : 


RADIUM  IN  GENERAL  DISEASES 


357 


(1)  Time,  say,  24  Hours. 

(2)  Quantity  of  radium,  200  mgrms. 

(3)  Activity  of  radium,  2,000,000. 

(4)  Thickness  of  filter,  2  mm.  platinum. 

(5)  Distance  from  periphery,  5  centimetres. 

(6)  KnoAvn  physiological  effect  upon  healthy  skin. 


RADIUM   IN   GENERAL   DISEASES 

While  great  claims  are  made  by  many  authorities  of  standing  as  to  the 
efficacy  of  radium  emanation  in  the  treatment  of  many  intractable  diseases, 
it  should  be  pointed  out  that  a  great  deal  of  thorough  investigation  is  neces- 


The  apparatus  consists  of  two  vessels. 
B  and  F.  Insoluble  sulphate  of  radium 
is  placed  in  the  small  receptacle  C  in 
the  vessel  F. 

In  order  to  use  the  apparatus,  the 
stopper  &j,  with  the  vessel  B,  is  raised. 
The  vessel  F  is  then  filled  with  the 
water  or  other  liquid  which  is  required 
to  be  rendered  radioactive.  The  cork 
6.2  is  replaced,  and  after  having  removed 
6j,  the  vessel  B  is  filled  with  the  same 
liquid,  and  b^  is  replaced. 

The  emanation,  which  is  given  off 
slowly  from  the  salts  of  radium,  is 
absorbed  little  by  little  by  the  liquid 
in  the  vessel  F,  and  as  this  is  drawn 
off  by  the  tap  R,  it  is  replaced  by  a 
corresponding  quantity  of  liquid  from 
B,  which  runs  through  the  tube  Tg  ^^^ 
emerges  under  the  receptacle  C  by  a 
little  hole  provided  for  this  purpose. 
The  air  can  enter  B  by  the  water  tube 
T-^,  but  it  cannot  come  out. 


Fig.  236. — Eadiogeue.     (Siemens.) 

sary  before  these  claims  can  be  recognised  as  of  value  in  a  number  of  these 
diseases.  The  chief  benefit  obtained  by  patients  after  taking  emanation 
in  solution  appears  to  be  a  feeling  of  well-being,  and  a  gradual  improvement 
in  the  general  health. 

The  blood  -  pressure   appears  to    be    reduced,   though,   when    careful 


358  EADIATION  THEEAPEUTICS 

observations  are  made  on  the  blood-pressure  of  patients  taking  radium 
emanation,  a  permanent  reduction  in  it  is  not  easily  detected.  The 
patients  so  treated  are  generally  visitors  to  well-known  health  resorts, 
and  while  residing  there  are  under  dietetic  and  hygienic  conditions  which 
are  not  so  faithfully  carried  out  under  other  conditions.  It  is  possible  that 
the  wholesome  regime  of  these  resorts,  early  hours,  and  restrictions  in  food 
and  drink  are  contributing  factors  to  the  general  improvement ;  nevertheless 
there  are  cases  which  have  benefited  from  emanation  treatment  in  their 
homes,  while  conversely  there  are  many  others  which  do  not  seem  to  improve 
at  all. 

While  patients  suffering  from  general  diseases,  such  as  gout,  diabetes, 
and  arteriosclerosis,  are  perhaps  best  treated  at  a  recognised  spa,  it  is  possible 
to  treat  such  cases  in  hospital  or  in  their  homes.  Hospital  treatment  is  the 
better  method,  because  then  it  is  possible  to  have  the  patient  under  control, 
and  all  contributing  factors  may  be  considered,  and  experimental  investiga- 
tions carried  out.  These  observations  should  be  carried  out  on  a  large  scale, 
and  an  opinion  on  the  value  of  radium  emanation  in  these  diseases  reserved 
until  it  is  possible  to  compare  a  large  number  of  statistics. 

The  strength  of  the  emanation  employed  must  be  known,  and  the  daily 
quantity  given  measured.  Such  observations  can  only  be  carried  out  in  a 
hospital  or  institution  which  has  the  necessary  accommodation,  and  a  fully 
equipped  laboratory,  where  physical  data  may  be  standardised,  clinical 
observations  made,  chemical  and  bacteriological  investigations  carried  out, 
and  the  whole  correlated  in  order  to  give  the  information  needed.  It  is 
satisfactory  to  know  that  these  conditions  are  now  existent  in  several 
institutions,  and  that  a  great  deal  of  research  work  is  going  on,  which  when 
published  should  go  far  towards  establishing  radium  as  a  therapeutic  agent 
of  known  and  proved  value. 

The  administration  of  radium  emanation  solution  of  a  strength  of  not 
less  than  1  milli-curie  per  litre  to  patients  suffering  from  chronic  arthritis, 
from  whatever  cause  it  may  be  due,  is  often  followed  by  marked  improvement 
in  the  condition  of  the  patient.  Cases  treated  comparatively  early  in  the 
course  of  the  disease  benefit  more  readily.  The  condition  of  the  joints  is 
also  of  importance.  The  periarticular  variety  is  the  most  likely  to  respond. 
When  there  are  marked  cartilaginous  and  osseous  changes  present,  little 
permanent  improvement  need  be  looked  for.  When  Hmitation  of  movement 
is  due  to  changes  around  the  joint,  and  these  are  not  at  an  advanced  stage, 
some  improvement  is  almost  certain  to  follow.  Pain  is  lessened,  the  grating 
in  the  joint  on  movement  is  not  so  marked,  and  the  muscular  and  the  general 
tone  improve. 


RADIUM  IN  DISEASES  OF  THE  EYE 

Mackenzie  Davidson  has  called  attention  to  the  marked  effect  of  radium 
in  diseases  of  the  eye,  trachoma,  conjunctivitis,  and  catarrhal  folliculitis. 


EADIUM  IN  GENERAL  DISEASES 


359 


Short 'exposures  are  recommended,  and  the  radium  should  not  be  screened 

to  any  extent.     The  radium  enclosed  in   a 

glass  tube,  or  very  thin  metal  filter,  is  the 

best  form  of  application,  and  a  few  minutes' 

exposure  is  all  that  is  necessary.      Each  case 

must,   however,    be  treated    on    its   merits, 

and  if  short  exposures  do  not  produce  the 

effect  wished  for  the  time  of  exposure  must 

be  increased. 

Rodent  ulcers  in  the  neighbourhood  of 
the  orbit  require  special  treatment.  When 
situated  on  the  eyelids,  the  eyeball  must  be 
protected  when  a  long  exposure  is  contem- 
plated. A  sheet  of  lead,  rubber,  or  lead 
enclosed  in  gutta-percha  tissue  is  moulded  to 
the  surface  of  the  eyeball,  and  placed  under 
the  lid  to  be  treated.  The  applicator  is 
strapped  in  position  for  the  necessary  time 


Fig.  237. — Application  of  radium  to 
the  eyelid. 

R.  Radium  tube. 

B.  Growth  on  upper  eyelid. 

C.  Lead  rubber  placed  under  eyelid 
to  protect  the  eyeball. 

It  will  be  found  that  com- 


paratively long  exposures  may  be  given  when  these  precautions  are  taken. 


RADIUM   IN   DISEASES   OF  THE   EAR,   NOSE,  AND 

THROAT 

In  these  regions,  owing  to  the  scarcity  of  the  supply  of  radium,  and  the 
consequent  difficulty  of  obtaining  sufficiently  large  quantities,  its  use  has  been 
restricted  to  malignant  disease.  But  it  is  probable  that  in  the  future  a  large 
field  of  usefulness  will  be  found  in  the  treatment  of  simple  inflammatory 
lesions.  In  the  region  of  the  ear,  nose,  and  throat  it  will  be  found  extremely 
useful  as  a  therapeutic  agent  of  great  potency,  and  probably  when  radium 
has  found  its  level  in  the  treatment  of  mahgnant  disease,  some  of  its  thera- 
peutic properties  will  be  directed  towards  the  cure  of  these  simpler  diseases. 

Granulation  tissue  readily  jdelds  to  radiation  treatment.  Haemorrhage 
can  be  controlled,  and  when  a  suppurative  condition  exists,  the  discharge 
may  be  greatly  lessened,  and  eventually  dried  up.  Chronic  inflammatory 
thickenings  will  slowly  subside  under  properly  estimated  radiation  dosage. 
Tubes  of  emanation  can  be  readily  moulded  to  a  suitable  size  for  introduction 
into  the  ear,  nose,  and  throat. 

Papillomata  of  the  vocal  chords  have  been  successfully  treated.  Chronic 
suppurative  conditions  of  the  ear  with  extensive  formation  of  granulation 
tissue  will  slowly  subside,  and  a  return  to  the  normal  follows. 

A  good  deal  has  been  written  on  the  treatment  of  deafness  by  radium. 
A  considerable  experience  of  the  action  of  both  X-rays  and  radium  leads 
one  to  state  that  the  percentage  of  cases  which  show  any  deflnite  improve- 
ment is  remarkably  small.  This  is  not  surprising  when  we  consider  the 
condition  of  the  parts  in  the  majority  of  the  cases  of  chronic  deafness.  Now 
and  again  a  case  which  is  suitable  may  show  a  good  deal  of  improvement. 


360  KADIATION  THERAPEUTICS 

but  any  permanent  good  result  must  not  be  expected.  In  the  majority  of 
cases  of  chronic  deafness  the  hope  of  improvement  through  the  use  of  radium 
should  not  be  held  out  to  the  patient.  The  treatment  of  such  cases  can  only 
bring  discredit  upon  the  agent  employed. 

RADIUM  IN  THE  TREATMENT  OF  EXOPHTHALMIC 

GOITRE 

It  is  to  be  expected  that  radium  should  exercise  a  beneficial  influence 
over  this  disease.  The  undoubted  success  of  X-ray  treatment  led  workers 
to  experiment  with  the  radiations  from  radium.  When  X-rays  alone  are 
used  the  hard  filtered  ray  appears  to  be  the  most  useful.  Radium  may  be 
combined  with  this  either  together  or  alternately.  When  a  patient  is  too 
ill  to  be  moved  daily  to  the  X-ray  room,  radium  may  be  applied  while  he  is 
resting  quietly  in  bed.  A  prolonged  exposure  is  necessary,  extending  into 
several  hours,  and  depending  on  the  quantity  used.  Using  100  mgrms. 
with  3  mm.  of  lead  filter,  twelve  hours  to  each  side  of  the  enlarged  thyroid 
gland  should  suffice  to  produce  marked  improvement.  The  exposures  may 
be  repeated  in  from  three  to  four  weeks.  After  one  or  two  applications 
a  marked  diminution  of  the  pulse  rate  is  obtained,  this  being  followed  by 
an  improvement  in  the  general  condition  of  the  patient.  Several  exposures 
at  long  intervals  should  be  given  after  the  symptoms  have  improved. 
Radium  may  be  used  when  all  other  remedies  have  failed.  Dawson  Turner 
has  recorded  a  number  of  cases  treated  by  radium  which  are  encouraging. 

MALIGNANT  DISEASE   OF  THE   THYROID   GLAND 

Radium  also  plays  an  important  part  in  the  treatment  of  enlarged 
thyroid ;  malignant  disease,  especially  sarcoma,  may  yield  to  radium  ; 
apparently  inoperable  cases  may  be  rendered  operable,  while  an  improvement 
in  the  condition  of  the  patient  is  almost  invariable.  The  gland  diminishes 
in  size,  distressing  symptoms  are  relieved,  and  in  some  instances  the  growth 
diminishes  greatly  in  size.  The  technique  in  these  serious  cases  is  different 
from  that  in  cases  of  simple  enlargement.  Large  quantities  of  radium  must  be 
used,  long  exposures  should  be  given,  and  the  whole  area  of  the  growth  and 
the  lymphatic  distribution  carefully  treated.  In  one  case  successfully  treated, 
205  mgrms.  of  radium  bromide  filtered  through  3  mm.  of  lead  at  a  distance 
of  3  inches  from  the  sldn  were  left  in  position  for  seventy-two  hours,  spread 
over  three  areas,  taking  in  all  the  enlargement.  The  enlarged  gland  slowly 
subsided.  There  was  no  superficial  reaction  at  all.  In  three  months 
nothing  could  be  felt  of  the  tumour,  except  a  slight  thickening  on  the  right 
side  of  the  gland.  From  a  consideration  of  the  results  obtained  in  a  large 
number  of  cases  of  enlarged  thyroid  with  constitutional  disturbances,  the 
conclusion  has  been  arrived  at  that  radium  offers  a  prospect  of  greater  and 
quicker  benefit  than  when  X-rays  are  used.  It  is,  moreover,  easier  to  apply, 
and  the  dosage  may  be  given  at  longer  intervals. 


RADIUM  IN  DISEASES  OF  THE  SKIN 


361 


RADIUM  IN  THE  TREATMENT  OF  DISEASES  OF 

THE   SKIN 

Many  of  the  diseases  of  the  integument  respond  to  radium  treatment 
when  other  remedies  have  failed.  When  the  lesion  is  superficial,  it  is  best 
to  employ  the  flat  applicators.  When  deeper  effects  are  required,  it  is 
necessary  to  use  the  Gamma  ray  with  filters.  The  conditions  which  are 
peculiarly  responsive  to  radium  are  occasionally  those  which  do  not  give 
good  results  with  any  of  the  other  agents 
used.  Vascular  nsevi,  hairy  moles,  warts, 
and  rodent  ulcer  respond  well  in  most  cases. 
Chronic  eczema,  psoriasis,  and  other  diseases 
of  a  like  nature  readily  respond  to  radium 
treatment.  In  place  of  the  flat  applicators 
prepared  in  varnish,  a  glass  applicator  of 
the  requisite  shape  may  be  used.  This  is 
charged  with  emanation,  and  may  be  ap- 
plied directly  to  the  skin  without  a  filter,  or 
simply  wrapped  in  a  piece  of  gauze  or  lint. 
The  advantage  of  this  form  of  applicator 
lies  in  the  fact  that  it  can  readily  be  dis- 
infected, and  can  be  repeatedly  recharged  when  required.  These  glass 
applicators  may  be  made  in  a  variety  of  shapes  to  suit  particular  cases. 

The  exposure  varies  with  the  quantity  of  radium  used,  its  degree  of 
activity,  and  the  filters  employed.  Consequently  the  estimation  of  the 
exposure  is  always  a  matter  of  difficulty. 

When  large  areas  have  to  be  treated,  it  is  necessary  to  continue  the 
exposure  over  the  whole  surface  by  moving  the  applicator  after  the  adequate 
exposure  has  been  given.     A  certain  degree  of  overlapping  occurs,  but  if 


Fig.  238.- — ^Circiilar  applicator  suitable 
for  the  treatment  of  superficial  skin 
lesions.      (Armbrecht,  Nelson  &  Co.) 


Fig.  239. — Applicator  iii  box.     (Siemens.) 
This  form  is  particularly  useful  in  the  treatment  of  superficial  skin  lesions. 

the  applicator  is  kept  at  a  distance  from  the  skin  by  means  of  several  layers 
of  lint,  the  danger  of  an  overdose  to  a  particular  area  is  greatly  diminished. 


362  EADIATION  THERAPEUTICS 

Psoriasis. — Other  methods,  notably) X-rays  filtered,  give  good  results. 
The  technique  is  similar  to  that  employed  in  chronic  eczema.  When  the 
radium  is  enclosed  in  platinum  tubes,  the  same  procedure  is  necessary,  but 
it  must  be  remembered  that  in  this  case  a  hard  ray  is  being  employed,  because 
I  to  I  mm.  of  platinum  (the  average  thickness  of  the  tubes  used  to  hold  the 
radium)  is  known  to  cut  off  a  large  percentage  of  the  Beta  rays  as  well  as  the 
Alpha  rays.  To  obtain  the  same  area  of  action  as  when  the  flat  applicators 
are  used,  two  or  more  of  the  small  tubes  may  be  employed,  longer  exposures 
being  necessary.  When  using  unscreened  applicators  the  exposures  will  be 
short,  and  given  at  frequent  intervals  on  several  successive  days.  Then  an 
interval  of  two  or  three  weeks  is  allowed  to  elapse  before  treatment  is 
resumed.  This  disease  is  apt  to  recur  at  long  intervals  of  time,  and  several 
series  of  treatment  may  be  required. 

Eczema. — The  use  of  radium  in  the  treatment  of  these  conditions  must 
necessarily  be  limited  to  cases  which  are  circumscribed,  e.g.  chronic  cases 
which  have  resisted  all  other  forms  of  treatment  may  receive  the  stimulus 
necessary  to  start  the  healing  process.  Flat  applicators  or  tubes  may  be 
employed,  the  exposures  varying  with  the  filtration.  A  flat  applicator  con- 
taining 5  mgrms.  of  radium,  spread  over  a  surface  of  2  by  1  cm.,  will  give  a 
marked  reaction  in  from  forty  to  sixty  minutes.  One  application  may  lead 
to  a  marked  improvement,  though  several  will  be  necessary  in  most  cases. 
Shorter  exposures  will  frequently  give  real  improvement,  and  these  should 
be  repeated  at  intervals  of  several  days,  until  a  slight  superficial  reaction 
appears.  When  this  subsides  the  condition  gradually  improves.  Treat- 
ment should  be  repeated  in  a  fortnight  to  three  weeks'  time,  and  the  case 
should  be  kept  imder  observation  for  several  months,  in  order  to  check  the 
earliest  appearance  of  a  recurrence. 

Nsevus. — Radium  possesses  a  great  advantage  over  other  methods  of 
treatment  in  that  its  use  is  painless,  and  that  there  are  no  distracting  noises 
from  active  apparatus.  In  children  this  is  important.  Nsevi  may  be  treated 
in  young  infants,  the  applicator  being  strapped  in  position  and  left  for  the 
required  time.  Further,  applicators  may  be  made  to  fit  angles  or  may  be 
inserted  into  the  cavities  of  the  body  or  into  the  interior  of  an  ulcerated  cavity 
or  the  substance  of  a  growth. 

In  treating  neevi  it  is  necessary  to  give  frequent  exposures  to  the  part. 
After  a  time,  usually  a  week  or  ten  days,  reaction  of  the  surface  appears. 
This  may  be  all  that  is  required,  the  resulting  changes  from  the  inflammatory 
processes  induced  in  the  tissues  leading  to  a  disappearance  of  the  vascu- 
larity. Should  the  apphcation  not  be  sufiicient  to  induce  these  changes  it 
must  be  repeated.  The  results  obtained  cannot  be  surpassed  by  any  other 
remedy,  and  the  process  is  quite  painless,  a  most  important  point  where 
young  children  require  to  be  treated.  The  resulting  scars  are  soft  and  flexible, 
and  in  time  the  skin  takes  on  quite  a  normal  appearance.  The  time  required 
for  thorough  treatment  is  sometimes  a  drawback,  but  if  the  treatment  is 
carefully  carried  out  the  result  amply  repays  the  trouble  taken. 

It  is  a  good  routine  method  to  begin  treatment  in  these  cases  with 


RADIUM  IN  DISEASES  OF  THE  SKIN  363 

unscreened  applicators,  and  give  short  exposures.  Time  should  be  allowed 
between  the  exposures  to  determine  the  degree  of  reaction.  It  is  most 
important  not  to  overdo  the  exposure,  because  if  this  occurs  troublesome 
telangiectasis  will  follow.  If  this  happens  it  may  be  necessary  to  treat  the 
condition  mth  electrolysis,  or  better  still,  the  point  where  the  dilated  vessels 
appear  may  be  treated  mth  a  diathermy  needle.  Very  good  results  will  follow 
these  appUcations.  In  some  cases  it  is  better  to  treat  these  conditions  at 
once  with  electro-coagulation. 

Nsevi  may  be  classified  clinically  as  follows  : 

1.  Flat  Superficial  Ncevi. — These  respond  well  to  radium  treatment. 
In  selecting  cases,  the  deciding  factor  is  the  degree  of  vascularity.  If  the 
parts  blanch  well  when  pressure  is  applied,  the  probabihty  is  that  the  response 
to  treatment  will  be  good. 

2.  Capillary  Ncevi. — These  also  respond  well,  but  before  beginning 
treatment  with  radium  other  methods  should  be  carefully  considered,  as 
carbon  dioxide  snow,  electrolysis,  or  diathermy  are  all  very  efficacious. 

3.  Port  Wine  Stains. — This  variety  is  not  at  all  easily  treated.  The  stains 
respond  slowly,  and  require  repeated  treatment,  and  often  in  the  end  the  result 
is  not  good.     These  remarks  apply,  however,  to  any  other  line  of  treatment. 

4.  Cavernous  NcBvi. — As  a  rule,  these  respond  very  well.  Filtered  rays 
should  be  employed,  and  the  exposure  may  be  given  at  one  sitting,  or  if 
more  convenient  it  may  be  divided  into  several  of  two  hours'  duration  on 
successive  days.  Eeaction  on  the  surface  is  not  desirable,  and  can  be  avoided 
by  adequate  filtration. 

Superficial  Papillomata  (Warts). — These  may  be  successfully  treated 
in  nearly  every  case  if  the  dose  is  accurately  estimated.  They  tend  to 
reappear  if  treatment  is  discontinued  too  soon.  An  exposure  of  one-half 
to  one  hour  with  an  unscreened  apparatus  will  cause  reaction  and  lead  to  a 
gradual  disappearance  of  the  wart.  The  tendency  is  for  recurrence,  and  the 
radium  exposures  may  be  repeated  when  necessary. 

Lupus  Erythematosus. — An  improvement  in  this  condition  may 
follow  radium  treatment,  but  the  exposures  require  to  be  continued  for  long 
periods  and  at  frequent  intervals.  X-rays  and  the  mercury- vapour  lamp 
often  give  quite  as  good  results. 

Lupus  Vulg-aris. — This  is  a  condition  where  many  methods  of  treatment 
may  require  to  be  used.  There  are  cases  where  radium  appears  to  be  the 
best  of  all ;  others  respond  to  X-rays,  and  others  again  to  the  mercury- 
vapour  lamp.  When  the  disease  is  situated  in  the  neighbourhood  of  the  nose, 
radium  is  the  most  useful  agent,  because  it  can  so  conveniently  be  appHed 
to  the  interior.  The  screened  rays  appear  to  act  best,  but  in  some  cases  an 
emanation  tube  with  a  rubber  tube  over  it  gives  excellent  results  when  long 
exposures  are  given. 

Cheloid. — Extensive  cheloid  is  a  condition  which  slowly  responds  to 
radium  treatment.  The  exact  line  of  treatment  must  be  determined  for 
each  individual  case.  Eadium  of  low-grade  activity  is  used  on  flat  applica- 
tors without  other  filtration  than  that  of  the  varnish  and  a  thin  layer  of 


364  RADIATION  THERAPEUTICS 

gutta-percha  tissue,  the  latter  being  employed  mainly  to  protect  the  surface 
of  the  plaque.  The  whole  of  the  scar  tissue  should  receive  an  equal  amount 
of  radiation,  and  care  should  be  taken  that  the  edges  of  the  cheloid  and  the 
adjoining  healthy  tissue  are  also  treated.  Until  the  operator  knows  the 
activity  of  the  applicator,  it  is  well  to  give  a  preliminary  exposure  over  a 
part  of  the  cheloid  for,  say,  an  hour,  and  then  to  wait  until  reaction  shows 
itself.  Having  thus  ascertained  the  necessary  degree  of  reaction,  the  whole 
of  the  scar  tissue  can  be  radiated,  an  equal  exposure  being  given  to  every 
part.  A  moderate  degree  of  reaction  is  necessary,  and  treatment  should 
be  suspended  until  this  has  subsided.  The  exposure  should  then  be 
repeated,  the  duration  of  time  being  increased  or  diminished  according  to 
the  results  obtained  from  the  preliminary  exposure. 

When  the  radium  is  enclosed  in  platinum  tubes  the  procedure  is  the 
same,  but  in  this  case  it  must  be  remembered  that  a  harder  ray  is  being 
employed,  because  ^  to  |  mm.  of  platinum  (the  average  thickness  of  the 
tubes  used  to  hold  the  radium)  is  known  to  cut  off  a  large  percentage  of  the 
Beta  rays  as  well  as  all  the  Alpha  rays. 

To  obtain  the  same  area  of  action  as  when  using  a  flat  applicator,  two  or 
more  of  the  small  tubes  may  be  enclosed  in  a  larger  applicator,  thicker  on 
one  side  than  on  the  other  ;  such  an  applicator  is  shown  in  Fig.  232.  The 
time  of  exposure  must  be  proportionately  lengthened  according  to  the 
thickness  of  the  radium  tubes,  and  the  external  filter  employed. 

With  applicators  having  tubes  of  a  thickness  of  |  mm.,  the  exposure  may 
safely  run  into  four  to  six  hours.  With  a  filter  of  1  mm.  the  time  might 
be  extended  to  six  or  eight  hours,  and  with  a  filter  of  2  mm.  or  more  the 
exposures  may  be  up  to  twenty  hours. 

In  all  these  instances  the  employment  of  two  or  more  layers  of  surgical 
lint  is  recommended,  this  also  serving  the  purpose  of  preventing  damage 
from  secondary  radiations  produced  in  the  filter. 

Leucoplakia. — This  condition  responds  readily  to  radium.  In  situa- 
tions such  as  the  mouth,  tongue,  etc.,  radium  is  probably  the  best  therapeutic 
agent  which  can  be  employed,  largely  on  account  of  the  ease  with  which  it 
can  be  applied  to  the  leucoplakial  patch.  This  condition  is  frequently  a 
forerunner  or  an  accompaniment  of  cancer.  When  the  latter  disease  has 
established  itself,  it  renders  the  prognosis  more  grave,  though  very  early 
cancer  may  be  healed  for  a  time  at  least. 

Prolonged  treatment  is  necessary,  and  the  radium  application  has  to 
be  well  screened  to  avoid  damage  to  the  healthy  tissues.  When  large  areas 
require  to  be  treated  it  is  advantageous  to  combine  X-rays  with  the  radium, 
thus  enabling  the  area  to  be  more  rapidly  treated.  Special  portions  may  be 
subjected  to  a  longer  radium  exposure. 

Pruritis. — In  the  treatment  of  this  disease  advantage  is  taken  of  the 
well-known  analgesic  powers  of  radium.  The  condition  is  accompanied  by 
a  degree  of  chronic  infiltration  of  the  skin,  and  the  object  of  treatment  is, 
therefore,  to  restore  the  skin  to  a  normal  condition  before  a  permanent  benefit 
is  obtained.     In  chronic  cases  this  is  extremely  difficult.     A  marked  degree 


RADIUM  IN  GYNAECOLOGICAL  PRACTICE  365 

of  reaction  is  necessary,  and  this  may  lead  to  an  aggravation  of  the  symptoms 
for  a  time.  Patients  are  consequently  discouraged,  and  it  is  difficult  to 
induce  them  to  continue  a  treatment  which  appears  to  be  doing  more  harm 
than  good.  If  treatment  is  persevered  with,  marked  benefit  will  follow  in 
a  large  percentage  of  cases.  Filtered  rays  and  long  exposures  are  necessary  ; 
1  mm.  of  silver  or  lead  should  be  employed,  and  several  layers  of  hnt  inter- 
posed between  the  tube  and  the  skin.  In  other  cases  it  may  be  necessary  to 
use  filters  of  platinum  up  to  2  mm.  Twelve  to  fifteen  hours'  exposure  of 
50  mgrms.  of  RaBrg  may  be  given,  and  this  dose  repeated  in  three  to  four 
weeks,  care  being  taken  not  to  overdo  the  exposures. 


RADIUM   IN  GYNi^COLOGICAL  PRACTICE 

The  diseases  in  which  radium  will  be  found  most  useful  are  : 

(1)  Chronic  endocervicitis. 

(2)  Chronic  endometritis. 

(3)  Leucoplakia  vulvae. 

(4)  Cancer. 

(5)  Fibro-myomata. 

A  short  description  of  the  technique  in  each  of  these  diseases  is  necessary, 
with  an  approximate  estimation  of  the  results  and  degree  of  benefit  received. 

Chronic  Inflammatory  Conditions  of  the  Cervix. — These  may 
be  treated  by  two  methods  : 

1.  The  introduction  of  a  metal  tube  containing  radium  into  the  cervical 
canal,  with  additional  tubes  arranged  in  the  fornices,  around  the  lips  of  the 
cervix,  when  disease  is  situated  here.  The  metal  tube  can  be  firmly  fixed 
to  a  sound,  to  facilitate  its  introduction. 

2.  An  emanation  tube  can  be  made  to  suit  the  particular  case  requiring 
treatment.  It  is  charged  with  the  emanation,  so  as  to  allow  of  full  activity 
at  the  time  of  application.  It  is  possible  to  have  the  appKcator  so  made  as 
to  contain  emanation  equal  to  100  mgrms.  of  radium  or  more  in  a  very  small 
cubic  space,  or  if  it  is  desirable  to  weaken  the  action,  the  applicator  may 
be  made  larger,  and  the  gas  allowed  to  difi:use  itself  over  the  larger  space. 

The  size  and  shape  of  the  applicator  and  the  quantity  of  radium  or 
emanation  to  be  used  being  thus  arranged,  the  next  matter  is  the  exposure. 
This  is  largely  a  matter  of  experience,  and  each  case  must  be  judged  on  its 
own  merits. 

Chronic  Endometritis. — When  there  has  been  considerable  hgemor- 
rhage  which  cannot  be  controlled  by  other  methods,  a  radium  tube  may  be 
introduced  into  the  body  of  the  uterus.  The  rays  will  often  check  the 
haemorrhage,  and  also  the  seropurulent  discharge  which  accompanies  the 
condition.  The  exposures  should  be  long,  and  filtration  is  necessary  if  it  is 
desired  to  influence  changes  in  the  deeper  layers  of  the  endometrium.  The 
treatment  should  be  continued  at  intervals  of  three  to  four  weeks,  until  the 
condition  has  returned  to  a  normal  state. 


366 


EADIATION  THEEAPEUTICS 


Leucoplakia  Vulvse. — This  condition,  which  causes  much  discomfort 
both  mentally  and  physically,  is  frequently  greatly  relieved,  and  often  occa- 
sionally quite  cured  by  thorough  radiation  treatment.  In  some  cases  X-rays 
are  found  to  be  more  useful  than  radium,  while  in  others  radium  acts  like  a 
charm.  Sometimes  it  is  well  to  apply  a  radium  tube  to  those  portions  of 
the  affected  area  where  the  disease  seems  most  active,  and  to  treat  the  more 
widely  but  less  deeply  affected  sldn  areas  with  X-rays. 
By  combining  the  agents  it  is  often  possible  to  get  much 
better  results  than  when  either  is  used  separately.  The 
exposures  should  be  frequent,  once  or  twice  a  week  for 
several  weeks.  When  frequent  doses  are  given,  filtration 
is  necessary,  and  it  should  be  increased  in  proportion 
to  the  frequency  of  the  dosage.  The  radium  should  be 
apphed  in  large  quantities,  filters  of  1  to  2  mm.  of 
platinum  enabhng  exposures  of  up  to  twenty-four 
hours  to  each  area  to  be  given.  In  the  early  stages  of 
treatment,  however,  it  is  better  to  give  divided  doses 
with  light  filtration,  and  wait  for  a  reaction  on  the  skin. 
If  this  reheves  the  irritation  (it  occasionally  increases  it) 
it  is  best  to  wait  till  this  reaction  subsides,  and  then  give 
another  dose,  filtered  this  time,  and  then  repeat,  increas- 
ing the  filtration  and  duration  of  the  exposure.  When 
all  irritation  has  subsided,  it  is  advisable  to  continue 
treatment  for  several  months,  in  order  to  carry  on  the 
beneficial  action  of  the  rays. 

Cancer  of  the  Cervix  Uteri. — Radium  treatment 
may  also  benefit  this  condition.  Haemorrhage  and  dis- 
charge are  lessened,  and  great  relief  from  pain  is  a 
frequent  result  of  treatment.  Active  treatment  by 
radium  in  cancer  of  the  cervix  has  5delded  encouraging 
results.  When  possible,  several  tubes  should  be  used. 
One  is  introduced  into  the  cervical  canal,  and  the  others 
placed  around  the  cervix,  these  being  packed  in  position 
with  tampons.  When  a  preHminary  partial  excision  has 
been  performed,  the  radium  tubes  are  introduced  while  the 
patient  is  under  the  anaesthetic.  In  all  cases  requiring 
treatment  the  use  of  an  anaesthetic  allows  of  the  placing 
of  the  radium  in  correct  position,  and  greatly  favours 
the  prospect  of  improvement.  Several  cases  of  early 
carcinoma  so  treated  have  done  remarkably  well.  Con- 
tinental writers  who  have  been  using  radium  and  mesothorium,  claim 
that  the  operative  treatment  of  cancer  of  the  cervix  is  no  longer 
necessary.  No  doubt  time  and  a  larger  experience  will  lead  them  to  con- 
siderably modify  this  opinion,  but  the  results  obtained  by  radium  treatment 
may  compare  very  favourably  with  those  obtained  by  operation.  The 
tendency  to  recurrence  exists  when  either  mode  of  treatment  is  followed. 


Fig.  240.  —  Uterine 
sound  with  radium 
tube  at  extremity. 
A  suitable  applicator 
for  introduction  into 
cavity  of  uterus. 
(Suggested  by  Mr. 
Lionel  Provis. ) 


EADIUM  IN  GYNECOLOGICAL  PRACTICE  367 

Time  alone  will  show  in  which  group  of  cases  the  larger  percentage  of  cures 
occurs.  Further,  radium  and  mesothorium  methods  may  improve  in 
technique,  and  so  improve  the  results.  Up  to  now  the  hard  ray  only  has 
been  most  largely  employed.  The  softer  Alpha  and  soft  Beta  rays  have  all 
been  excluded  by  filtration.  It  is  possible  that  by  using  emanation  in 
properly  shaped  and  suitably  sized  glass  tubes,  which  will  allow  the  softer 
rays  to  get  through,  a  more  favourable  action  may  be  induced. 

Exposures  of  Radium  in  treatment  of  Cancer  of  the  Cervix. — This  is  always 
a  matter  of  difficulty,  the  duration  depending  upon  the  object  to  be  attained. 
In  all  cases  a  filter  of  at  least  1  mm.  thick  is  necessary.  An  exposure  of  six 
hours  will  lead  to  considerable  reaction.  This  should  slowly  subside,  and 
cicatricial  changes  set  in.  When  2  mm.  of  platinum  are  used  the  exposure 
will  be  proportionately  longer,  twelve  to  fifteen  hours  being  necessary.  In 
advauced  cases,  where  there  is  a  considerable  amount  of  ulceration,  and  the 
radium  tube  can  be  placed  in  position  completely  surrounded  by  growth, 
much  longer  exposures  may  be  made  ;  twenty-four  hours  or  more  will  result 
in  the  breaking  down  of  the  ulcerated  surfaces  and  the  replacement  of  the 
tumour  tissue  by  fibrous  tissue.  In  early  cases  it  is  well  to  proceed  with 
caution,  giving  small  doses  at  frequent  intervals,  and  carefully  watching  for 
reaction  and  improvement.  When  the  latter  sets  in  it  should  be  continued 
by  judiciously  administered  doses  until  the  whole  of  the  growth  has  dis- 
appeared. When  such  a  fortunate  result  is  obtained,  it  is  still  necessary  to 
continue  treatment  with  thicker  filters,  in  order  to  reach  the  outlying  portions 
of  growth.  In  the  experience  of  several  workers  an  apparent  cure  of  the  local 
condition  has  been  followed  in  a  short  period  of  time  by  involvement  of  the 
deep  pelvic  glands,  and  a  rapid  development  of  these  has  led  to  the  death 
of  the  patient. 

While  radium  does  not  appear  to  exercise  any  specific  influence  over 
these  growths,  it  is  probable  that  if  the  radiations  could  be  apphed  in  suffi- 
cient intensity  the  growth  might  be  mitigated.  It  is  possible  that  the  doses 
given  for  the  local  condition  may  have  exercised  a  stimulating  effect  upon 
the  more  distant  portions  of  the  growth.  In  aU  exposures  the  ruling  factor 
is  the  quantity  of  radium  used.  The  doses  suggested  above  are  taken  as 
for  100  mgrms.  in  |  mm.  platinum  tubes,  and  at  least  1  mm.  of  silver.  When 
the  I  mm.  tube  alone  is  used,  the  exposures  are  proportionately  less. 

Treatment  of  Fibromata. — The  technique  described  in  the  treatment 
of  these  conditions  by  X-rays  shows  the  type  of  case  likely  to  derive 
benefit  from  the  treatment.  The  same  types  can  be  successfully  treated  by 
radium,  and  the  technique  will  depend  upon  the  quantity  of  radium  used. 
The  exposures  may  be  made  in  four  directions  : 

(1)  Through  the  anterior  abdominal  wall. 

(2)  From  the  perineal  aspect. 

(3)  Tubes  can  be  introduced  into  the  interior  of  the  uterus  and  vagina. 

(4)  From  the  back. 

The  two  agents  may  be  combined  :  X-ray  exposure  should  be  made  in 
the  usual  way,  and  a  radium  tube  or  tubes  introduced  into  the  vagina  and 


368  EADIATION  THEEAPEUTICS 

left  there  for  the  necessary  time.  Mesothorium  can  be  used  instead  of 
radium,  or  to  supplement  its  action  when  the  quantity  of  the  latter  available 
is  not  sufficient. 


RADIUM  IN   SUPERFICIAL  EPITHELIOMA  AND 
RODENT  ULCER 

These  are  numerous,  and  occur  in  many  situations  in  the  body.  Super- 
ficial, mildly-malignant  epitheliomata  yield  readily  to  radium  treatment, 
a  few  exposures  of  several  hours'  duration  to  a  case  of  this  kind  ending  in  a 
heahng  of  the  surface.  Such  cases,  however,  yield  quite  as  readily  to  X-ray 
treatment.  The  vegetating  cutaneous  epithelioma  comes  under  this  heading. 
Under  this  head  it  is  well  also  to  include  the  most  common  of  all  superficial 
lesions — the  rodent  ulcer. 

Early  cases  are  readily  influenced  by  treatment.  They  quickly  heal, 
but  prophylactic  doses  should  be  given  after  the  ulcer  has  healed.  If  the 
condition  is  quite  superficial  the  filtration  need  not  be  great.  The  Beta 
rays  appear  to  exercise  a  profound  change  in  these  cases.  After  healing  has 
taken  place  filtered  doses  should  be  used  to  reach  the  deeper  parts.  Even 
after  thorough  prophylactic  treatment  recurrences  are  apt  to  follow  at  longer 
or  shorter  intervals,  but  frequently  respond  to  further  treatment.  All  cases 
treated  should  be  kept  under  observation  for  a  considerable  time  in  order 
that  an  early  stage  of  the  recurrence  may  be  observed  and  promptly  treated. 

When  the  ulcer  is  large  and  involves  bone  and  cartilage  the  prospect  of 
a  cure  is  not  so  good.  Most  complete  and  powerful  dosage  may  fail  to  check 
the  progress  of  the  disease.  These  cases  may  even  be  stimulated  by  radium 
treatment,  and  increase  rapidly  in  size.  In  such  cases  it  is  better  to  combine 
surgical  measures,  such  as  scraping  or  excision,  with  radium  treatment. 
Several  cases  so  treated  have  healed  and  remained  well.  These  occur  in 
many  situations,  but  most  commonly  on  the  face,  at  the  angle  of  the  mouth, 
and  on  the  outer  or  inner  margin  of  the  orbit.  Many  of  these  heal  readily,, 
and  remain  healed ;  others  heal,  only  to  break  down  after  a  more  or  less 
lengthy  interval.      Recurrences  may  be  treated  as  they  occur. 

There  are  several  methods  of  treatment  for  this  condition  : 

(1)  Short  exposure  to  radium,  with  practically  no  screening.  A  marked 
reaction  may  be  induced,  which  may  end  in  ulceration  if  the  exposure  has 
been  unduly  prolonged.  When  this  subsides,  the  ulcer  heals  and  a  healthy 
scar  results. 

(2)  Long  exposures  with  thick  filters  of  2  or  more  millimetres  of  lead. 
The  Gamma  ray  is  almost  exclusively  employed  in  this  manner. 

(3)  Combined  X-ray  and  radium  exposures. 

It  has  been  observed  that  a  case  which  fails  to  respond  to  radium 
may  respond  to  X-rays  of  a  hard  type,  and  vice  versa.  This  is  contrary  to 
the  opinion  expressed  by  several  authorities,  who  maintain  that  a  case  which 
has  failed  to  improve  under  radium  treatment  will  fail  to  do  so  under  X-rays. 


PLATE  LXIII. — EoDENT  Ulcers  Treated  with  Radium  and  X-Rats. 

a,  Rodent  ulcer  of  upper  lip,  showing  rapid  improvement  under  combined  X-rays  and  radium  treatment. 
h.  Rodent  ulcer  of  side  of  nose  which  rapidly  healed  after  radium  had  been  applied.     The  ulcer  re- 
appeared after  about  nine  months,  but  again  quickly  healed  after  further  treatment. 


RADIUM  IN  RODENT  ULCER  369 

Some  assert  that  a  case  which  has  not  benefited  from  X-rays,  and  which  has 
had  prolonged  X-ray  treatment,  fails  to  show  improvement  when  treated  by 
radium.     Others  say  that  radium  invariably  heals  such  cases. 

In  the  experience  of  the  writer,  cases  respond  to  X-rays  and  radium 
according  to  the  state  of  activity  of  the  ulcer  at  the  time  of  treatment.  The 
ulcer  which  has  failed  to  improve  with  radium  will  sometimes  clear  up  in  a 
remarkable  manner  when  subjected  to  a  long  exposure  of  hard,  well-filtered 
X-rays. 

The  explanation  of  the  conflicting  opinions  probably  lies  in  the  fact  that 
it  is  a  particular  type  of  hardness  of  radiation  which  is  necessary  for  the 
therapeutic  effect,  and  when  this  type  is  available,  it  matters  not  whether  it 
is  produced  by  X-rays,  radium,  or  any  other  radioactive  body.  In  many 
of  the  cases  treated  which  do  not  improve,  or  get  rapidly  worse,  we  have  not 
been  using  the  correct  ray,  or,  if  we  have  done  so,  the  exposure  has  been  too 
short  to  produce  the  effect  which  should  result  in  healing.  This  is  probably 
the  explanation  of  the  conflicting  results  obtained  by  many  workers. 

Ulcers  situated  near  the  orbit,  nasal  cavities,  or  angle  of  the  mouth 
require  modifications  in  the  treatment.  Near  the  orbit,  care  must  be  exercised 
that  the  eyeball  and  conjunctiva  are  not  injured.  When  it  has  become 
involved  by  the  growth,  it  is  better  to  remove  it  and  thoroughly  scrape  the 
surrounding  tissues.  The  following  types  of  rodent  ulcer  have  been  treated 
with  more  or  less  success : 

Superficial  epitheliomata  of  the  side  of  the  face,  a  thin  mdespread 
superficial  growth  without  ulceration.  This  type  readily  responds.  Some 
of  these  cases  are  surrounded  by  nodules,  which  generally  disappear  slowly 
but  surely.  The  common  situation  is  the  malar  area.  The  lateral  aspect 
of  the  nose  is  another  area  which  is  often  affected,  the  ulcer  tending  to 
spread  into  the  orbit.  For  both  these  types  the  flat  appHcators  with  very 
light  screen  are  advocated  at  the  commencement  of  treatment ;  later  the 
thicker  filters  should  be  employed.  Ulcers  which  tend  to  extend  downwards 
into  the  tissues  and  spread  locally  are  more  difiicult  to  deal  with.  Such 
ulcers  are  very  apt  to  recur  after  treatment  is  stopped ;  deep  filtration 
should  be  employed  in  these  cases.  When  cartilage  and  bone  are  involved, 
the  cases  do  not  yield  so  easily.  Prophylactic  treatment  should  be  carried 
out  for  some  time  after  an  apparent  cure,  in  the  hope  that  a  recurrence  may 
be  prevented. 

In  regard  to  the  practical  application  of  radium  to  this  latter  type  of  case, 
it  may  be  claimed  that  when  the  growth  is  not  very  mahgnant,  radium  should 
be  given  a  good  trial ;  the  percentage  of  cures  obtained  compares  favourably 
with  the  percentage  obtained  in  cases  which  are  operated  upon.  The  results 
are  better  than  those  obtained  by  operation,  in  that  the  scar  is  soft  and  pfiant. 
The  convenience  of  application  and  the  freedom  from  pain  and  discomfort 
are  also  factors  in  favour  of  radium  treatment.  When  time  is  of  value  and 
aesthetic  considerations  of  no  great  moment,  the  operative  method  gives 
a  speedier  result.  Surgical  measures  may  be  profitably  combined  with 
radium  treatment.     Excision  or  scraping  of  the  actual  growth  and  after 

24 


370  RADIATION  THERAPEUTICS 

treatment  by  radium  mil  often  give  a  better  result  than  when  radium  alone 
is  used. 

RADIUM  IN  INFILTRATING  EPITHELIOMA 

These  occur  in  the  preauricular  and  other  regions.  They  show  peri- 
pheral inflammatory  changes  with  a  thickened  edge.  They  tend  to  heal 
spontaneously  in  parts  of  the  surface.  The  treatment  in  these  cases  must 
be  rigorous.  Deep  penetrating  rays  should  be  tried  after  superficial  healing 
has  taken  place,  and  a  number  of  prophylactic  doses  should  be  given.  An 
obstinate  variety  of  this  class  is  found  in  or  round  the  auricle,  and  frequently 
inside  the  meatus.  Radium  tubes  may  be  introduced  into  the  auricle  and 
left  there,  marked  inflammatory  reaction  being  necessary  before  any  improve- 
ment can  be  expected. 

Epithelioma  are  also  met  with  inside  the  nose  and  on  the  temple.  A 
form  very  difficult  to  deal  with  successfully  is  the  type  met  with  at  the  junc- 
tion of  skin  and  mucous  membrane.  Because  of  the  mixed  character  of  the 
cutaneous  surfaces  the  growth  presents  two  aspects  for  treatment,  that 
involving  the  skin  on  one  side  and  the  mucous  membrane  on  the  other. 

The  eyelid  is  occasionally  the  seat  of  these  growths.  Care  must  be 
taken  to  protect  the  organ  of  sight.  Screens  of  lead  with  lint  underneath 
are  required,  and  great  care  must  be  taken  to  ensure  correct  apposition  of 
the  radium  to  the  ulcer.  Epithelioma  of  the  nasal  mucous  membrane  is  a 
form  commonly  met  with,  and  one  in  which  it  is  extremely  difficult  to 
secure  healing  which  will  be  permanent. 

A  complete  excision  of  the  spreading  edge  and  subsequent  thorough 
prophylactic  treatment  are  measures  which  commend  themselves  to  the 
rational-minded  radium  therapist.  A  large  percentage  of  these  cases  go 
from  bad  to  worse,  in  spite  of  the  most  vigorous  radium  treatment.  They 
may,  however,  heal  up  for  a  time,  but  only  to  break  down  again.  It  is  only 
proper,  however,  to  point  out  that  a  number  of  these  cases  have  been  operated 
on,  and  repeated  recurrences  developed.  Operative  measures  to  be  success- 
ful must  be  thorough. 

Glandular  enlargement  when  present  must  be  very  thoroughly  treated. 
Such  enlarged  glands  yield  very  slowly  to  treatment  when  they  are  un- 
doubtedly malignant.  Some  cases  of  undoubted  carcinoma  of  the  tonsil  or 
breast,  with  many  enlarged  glands,  have  been  successfully  treated.  It  must 
be  borne  in  mind  that,  when  glands  appear  and  rapidly  enlarge  in  cases  where 
the  primary  growth  is  in  a  situation  where  a  mixed  infection  is  possible, 
a  part  of  the  enlargement  may  be  due  to  an  inflammatory  process  super- 
added to  the  malignant.     Such  cases  rapidly  yield  to  radium  treatment. 

After  a  growth  has  disappeared  under  radium,  it  is  important  to  continue 
the  applications  for  a  considerable  time,  at  regular  intervals,  in  the  hope  that 
recurrence  may  be  prevented.  The  area  immediately  surrounding  the 
growth  should  receive  thorough  irradiation,  and  also  the  area  of  lymphatic 
drainage. 


RADIUM  IN  CANCER  371 

RADIUM  IN  SARCOMATA  AND  CARCINOMATA 

These,  on  account  of  their  greater  extent,  deeper  infiltration,  and  more 
rapid  growth  are  classed  among  the  actively  malignant  group.  The  growth 
may  begin  in  the  same  situations  as  the  preceding,  and  are  often  at  the 
commencement  indistinguishable  from  the  less  malignant.  It  is  on  this 
account  that  the  need  for  early  operation  as  an  alternative  to  radium  therapy 
must  be  well  borne  in  mind.  Such  cases  frequently  fail  to  respond  favour- 
ably to  radium,  and  a  percentage  take  on  a  more  rapid  growth  as  a  conse- 
quence of  the  stimulating  effect  of  the  treatment.  Treatment  must  be  pushed 
rapidly  to  the  extreme  limit,  and  if  the  response  is  not  equally  rapid  and 
successful  then  the  question  of  operative  measures  must  be  at  once  considered. 

Sarcomata. — The  round-celled  variety  seems  to  be  the  type  of  growth 
most  readily  influenced  by  radium.  Large  tumours  may  gradually  diminish 
in  size,  smaller  growths  disappear,  while  secondary  glands  also  clear  up. 
The  spindle-celled  variety  is  not  so  readily  dealt  with,  possibly  because  it  is 
a  more  active  type  of  growth.  When  the  mediastinum  is  involved,  exposures 
may  be  made  over  the  sternum  and  ribs  in  the  hope  that  the  disease  may  be 
checked.  The  insertion  of  tubes  containing  radium  into  the  tumour  mass 
is  the  most  practical  method  of  treatment.  Several  tubes  may  be  inserted 
at  points  equidistant,  in  order  that  the  radiations  may  be  equally  distributed 
throughout  the  growth.  The  exposure  depends  upon  the  quantity  of  radium 
used,  the  size  and  type  of  the  growth,  and  the  filtration  employed.  In  a 
large  tumour,  a  tube  containing  50  mgrms.,  with  -5  mm.  filter  may  be  left 
in  situ  for  twenty-four  hours. 

When  the  growth  is  large,  several  tubes  introduced  at  equal  distances 
from  one  another  may  be  left  for  the  same  time.  In  any  particular  case 
when,  after  the  first  exposure,  no  marked  necrotic  changes  have  resulted, 
the  treatment  should  be  repeated,  and,  if  necessary,  the  exposure  may  be 
considerably  prolonged  until  the  desired  result  is  obtained.  When  the 
exposure  has  been  accurately  estimated,  the  tumour  slowly  subsides  without 
any  necrosis.  This  is  the  ideal  method  of  treatment,  but  it  frequently 
happens  that  the  correct  exposure  has  not  been  given,  and  either  no  change 
is  induced  and  the  growth  increases  in  size,  or  it  becomes  necrotic,  and  slough- 
ing takes  place.  This  latter  change  may  in  time  be  followed  by  a  healing 
of  the  ulcerated  surfaces.  An  attempt  should  always  be  made  to  treat  the 
outlying  edges  of  the  growth  and  the  surrounding  healthy  tissues.  Pro- 
phylactic treatment  should  be  continued  for  several  months  after  healing 
has  resulted. 

Recurrent  sarcoma  may  be  treated  by  external  applications  of  radium, 
several  cases  so  treated  having  cleared  up  and  these  still  remain  well.  The 
quantity  of  radium  used  should  be  as  large  as  possible,  200  or  300  mgrms.  in 
platinum  tubes,  with  2  to  3  mm.  filter  of  lead  and  about  twelve  layers  of  lint 
between  the  radium  and  the  skin  surface.  The  area  to  be  treated  may  be 
divided  into  several  portions,  and  an  exposure  of  twenty-four  hours  given 
to  each. 


372  RADIATION  THERAPEUTICS 

Cancer  of  the  Breast, — This  class  of  cases  forms  a  large  percentage 
of  those  sent  for  radium  treatment. 

Secondary  deposits  may  be  met  with  in  the  glands  of  the  axillary  and 
supraclavicular  regions.  These  may  be  treated  at  the  same  time  as  the 
primary  growth.  Secondary  deposits  in  the  cartilage  of  the  ribs  or  sternum 
may  also  require  treatment.  Prolonged  exposures  to  large  quantities  of 
well-filtered  radium  have  in  several  instances  led  to  a  diminution  in  the  size 
of  the  growth. 

The  rapidly  growing  columnar- celled  carcinomata  may  be  treated  with 
a  measure  of  success.  Tubes  containing  radium  should  be  buried  in  the 
growth,  and  left  for  long  periods.  A  diminution  of  the  growth  may  be 
looked  for,  but  the  prospect  of  a  cure  is  extremely  remote.  Less  rapidly 
growing  cases  are  more  amenable  to  treatment.  The  atrophic  scirrhus 
cancer  is  the  most  favourable  type  for  treatment.  In  some  cases  a  necrotic 
action  can  be  induced,  and  the  subsequent  ulcer  gradually  heals.  Glands 
should  be  treated  at  the  same  time,  and  after  healing  has  taken  place,  pro- 
phylactic treatment  should  be  carried  out  for  a  considerable  time. 

Cancer  en  Cuirasse. — This  variety  often  responds  well,  for  a  time  at 
least.  Enlarged  glands,  which  may  be  inflammatory  in  character,  are  a 
frequent  seat  of  late  involvement.  This  is  probably  the  result  of  direct 
spread  by  means  of  the  lymphatic  stream.  An  inflamed  gland  offers  a  suit- 
able soil  for  the  development  of  cancerous  cells.  Radium,  by  inducing 
fibrosis,  tends  to  seal  up  the  new  growth,  and  so  prevent  its  spread. 

Partial  success  in  dealing  with  these  conditions  may  lead  to  a  prolonged 
quiescent  stage,  which  may  resume  active  growth  later.  The  object  of  the 
prophylactic  treatment  is  to  prevent  this  late  recurrence. 

Recurrent  Cancer. — Secondary  growths  involving  cartilage  and  bone 
appear  after  amputation  of  the  breast.  Several  cases  of  this  class  have  been 
treated  with  marked  success,  with  radium  applied  in  large  quantities  for 
long  periods,  care  being  taken  to  protect  the  skin.  A  fairly-marked  skin 
reaction  may  be  obtained  after  long  exposure  to  filtered  radium,  this  slowly 
subsiding  and  resulting  in  no  permanent  damage. 

Recurrence  after  operation  frequently  requires  treatment.  Small 
nodules  readily  respond,  and  often  entirely  disappear.  Enlarged  glands  are 
reduced  in  size.  Radium  applicators  may  be  used  directly  over  particular 
glands  or  groups  of  glands  with  a  fair  measure  of  success.  In  a  number 
of  cases,  where  there  is  a  possibility  of  doing  good,  radium  tubes  may 
be  inserted  into  the  recurrent  mass. 

Radium,  in  the  treatment  of  diseases  of  the  breast,  should  be  strictly 
confined  to  cases  which  for  some  reason  are  unsuitable  for  operation.  Early 
cases  might  be  treated,  were  it  possible  to  place  complete  reliance  upon 
radium  as  a  curative  agent.  Cases  have  been  treated,  and  have  done  well, 
but  in  the  present  state  of  our  knowledge  it  is  impossible  to  give  radium  the 
first  place  in  the  choice  of  a  remedy.  In  all  cases  of  early  cancer  the  opera- 
tive method  is  undoubtedly  the  best ;  it  is  quicker,  safer,  and  offers  the  best 
prospect  of  a  cure.     It  must,  however,  be  stated  that  X-rays  are,  in  selected 


PLATE  LXIV.— Eectjreent  Caecinoma  after  Eemoval  of  Breast. 


«,  Recurrence  in  scar  after  operation  for  carcinoma  of  the  breast,  treated  wholly  by  X-rays. 
h,  Recurrence  in  scar  involving  steinum  and  ribs  after  oj)eration  for  removal  of  carcinoma,  treated  with 
radium,  jjrolonged  exposures  with  200  nigrnis.  of  radium  filtered  through  3  mm.  of  lead. 


KADIUM  IN  CANCER 


373 


cases,  quite  as  useful  as  radium.  In  patients  who  refuse  operation,  or  are 
for  other  reasons  not  suitable  for  operation,  radium  is  a  useful  remedy.  In 
inoperable  cases  radium  may  help  to  render  the  case  operable,  and  failing 
that  it  is  undoubtedly  useful  as  a  palliative  measure. 

When  a  large  tumour  of  the  inoperable  type  has  to  be  treated,  it  is 
useful  to  combine  X-rays  with  radium.  The  former  can  be  used  to  irradiate 
rapidly  the  tumour  area  and  the  lymphatics  draining  it,  and  after  a  time, 
when  the  tumour  has  subsided,  radium  tubes  may  be  introduced  into  the 
substance  of  the  growth  and  left  in  situ  for  two  days,  or  longer  if  necessary. 
The  treatment  results  in  considerable  shrinkage  in  the  size  of  the  tumour, 
and  it  is  quite  possible  to  render  an  inoperable  case  operable. 

The  classification  of  cases  for  radium  treatment  is  similar  to  that  given 
under  X-ray  therapeutics. 

RADIUM  IN  CANCER  OF  THE  TONGUE  AND  MOUTH 

This  condition  is  frequently  sent  for  radium  treatment.  Tubes  may 
be  buried  in  the  growth,  and  benefit  is  occasionally  obtained,  though  in 


Fig.  241. — Radium  tube  arranged  for  the  treatment  of  the  floor  of  the  mouth.     (Siemens. 
JV  shows  applicator  in  protective  material  with  handle.      0,  radium  tube.     F,  rubber  filter. 
Q,  protective  material.     <S',  cross  section.     T,  flat  applicator  arranged  in  a  similar  manner. 

this  class  of  case,  as  in  many  others,  operative  measures  should  come  first. 
Temporary  benefit  may  follow,  but  sooner  or  later  recurrence  shows  itself, 


374 


RADIATION  THERAPEUTICS 


and  this  may  take  on  a  very  active  form.  Cancer  of  the  floor  of  the 
mouth  is  a  condition  which  does  not  respond  favourably  in  a  large  number 
of  cases  treated.  When  possible,  tubes  should  be  buried  in  the  growth. 
When  this  is  not  done,  a  useful  form  of  apphcator  may  be  used  (see  Fig.  241). 
A  window  can  be  cut  in  the  lead  tube  surrounding  the  radium  tube,  the  rays 
passing  through  the  window  directly  on  to  the  growth,  while  the  surround- 
ing tissues  are  protected  to  some  extent  by  the  thick  lead. 


RADIUM  IN  CANCER  OF  THE  (ESOPHAGUS 


This  condition  has  been  treated  with  a  beneficial  result  for  a  time.     A 
number  of  patients  have  gained  weight,  and  retained  the  use  of  the  oesophagus 

up  to  the  time  they  died  of  secondary 
growth  in  the  mediastinum.  It  is 
important  that  the  stricture  should  be 
definitely  located  before  the  radium 
tube  is  introduced.  A  radiographic 
examination  with  a  bismuth  cachet 
or  semi-liquid  bismuth  is  used  to 
enable  us  to  recognise  the  stricture. 
A  radium  tube  in  a  platinum  filter, 
2  mm.,  is  attached  to  a  length  of 
pliable  silver  wire,  which  is  enclosed 
in  a  rubber  tube  of  2  mm.  thick 
to  cut  ofE  the  secondary  radiations. 
When  it  is  desirable  to  produce  a 
superficial  reaction  a  thinner  filter 
may  be  used,  a  -|-mm.  platinum  tube 
in  a  rubber  tube  being  used.  The 
exposure  is  proportionately  shorter,  a 
larger  percentage  of  the  Beta  rays 
being  employed.  The  tube  is  passed 
into  position  either  with  or  without  an 
anaesthetic  (in  most  cases  it  is  better 
to  give  an  anaesthetic),  and  then  with 
a  Brunning  apparatus  the  stricture 
can  be  examined,  and  if  necessary 
for  the  treatment  of    dilated  to  allow  of  the  passage  of  the 

growths  in  the  lower  -,.  .     -,  „,  ., 

radium    tube.       ihe    silver    wire    is 


Fig.  243.  — Tube  ar- 
ranged on  a  length 
of  pliable  silver  wire. 
This  is  a  convenient 
form    of    applicator 


Fig.  242.  —  Eadiiim 
tube  in  an  oesophageal 
tube,  arranged  for 
the  treatment  of  an 
oesophageal  growth. 


half  of  the  oesopha- 
gus. The  wire  keeps 
the  radium  tube  in 
position,  and  it  is 
tixed  outside  the 
mouth  with  adhesive 
plaster. 


brought  out  at  the  mouth  and  fixed 
to  the  side  of  the  face.  When  the 
exposure  is  finished  a  special  tube 
may  be  introduced  through  the 
stricture,  this  securing  the  double 
purpose  of  keeping  the  channel  open  for  a   time,  and  of  allomng  the 


RADIUM  IN  CANCER 


375 


patient  to  be  fed  through  the  tube.  The  duration  of  the  exposure  is  deter- 
mined by  the  quantity  of  radium  used  and  the  amount  of  growth  present. 
A  radiograph  may  be  taken  later  to  determine  if  the  radium  tube  has  been 
accurately  placed  in  the  stricture.  Reaction  follows  the  exposure,  and  the 
stricture  may  for  a  time  become  narrower  from  this  infiammator}-  reaction. 
Slou^hinfr  of  the  surface 
in  contact  with  the 
radium  tubes  may  occur, 
though  if  the  filtration 
is  adequate,  and  the 
exposure  accurately 
gauged,  this  need  not 
occur.  A  resolution  of 
the  growth  on  the  sur- 
face of  the  oesophagus 
may  be  induced  with 
little  or  no  sloughing. 
When  marked  sloughing 
has  occurred,  the  heal- 
ing process  which  follows 
may  lead  to  a  cicatricial 
narrowing  of  the  oesoph- 
agus, which  will  in 
effect  be  as  harmful  as 
the  original  stricture  due 
to  the  presence  of  the 
growth.  This  cicatricial  stricture  can,  however,  be  treated  by  the  passage 
of  bougies,  and  dilated  from  time  to  time.  The  dilatation  may  be  brought 
about  by  passing  a  Brunning  tube  past  the  stricture.  This  can  be  done 
in  the  course  of  the  repeated  examinations,  which  should  always  follow 
after  healing  has  been  brought  about. 


Fig.  2ii. — Shows  radium  tube  in  situ,  for  the  treatment  of  carci- 
uoma  of  the  oesophagus,  situated  close  to  the  cricoid  cartilage. 


RADIUM  IN  CANCER  OF  THE  RECTUM,  THE 
PROSTATE  GLAND,  AND  THE  BLADDER 


In  Cancer  of  the  Rectum 

S}Tnptoms  may  be  reheved  for  a  time.  The  tube  containing  the 
radium  must  be  passed  into  the  stricture,  otherwise  it  may  act  as  an 
irritant  to  the  healthy  mucous  membrane  and  increase  the  distressing 
symptoms  so  common  in  this  situation.  Emphasis  must  be  laid  on  the 
point  that  it  is  absolutely  essential  that  the  tubes  be  placed  in  the  midst 
of  the  growth.  This  can  only  be  done  when  the  lumen  of  the  bowel 
is   still  patent   and   the  growth  involves  the  whole   bowel.      The   growth 


376 


RADIATION  THERAPEUTICS 


shrinks,  and  the  function  of  the   bowel  may  be  restored  for  a  time  if    a 
sufficient  quantity  of  radium  is  used  and  a  long  enough  exposure  is  given. 

The  results  obtained  in  the  treat- 
ment of  this  disease  are  disappointing, 
largely  due  to  the  fact  that  the  majority 
of  cases    treated  are  advanced  ones, 
and  not  likely  to  improve,  whilst  the 
favourable  cases  which  offer  the  better 
chance  of  a  successful  result  are  rightly 
submitted  to  early  operative  measures. 
Filters  of  2  mm.  of  platinum,  and  rubber  tubing, 
should   be   employed ;   100  mgrms.   in  these  filters 
may  be  left  in  situ  for  about  fifteen  hours  for  an 
exposure.     This  may  be  repeated  in  a  month's  time. 
The  radium  tube  is  enclosed  in  rubber  tubing  2  mm. 
thick.   This  is  introduced  into  the  lumen  of  the  bowel, 
and  the  length  of  rubber  is  strapped  outside,  serving 
to  hold  the  radium  tube  in  position.     A  soft  rubber 
catheter  will  be  found  an  excellent  holder  for  the 
radium  tube.     A  thin  rubber  tube  placed  over  this 
one  and  sealed  at  one  end  serves  the  double  purpose 
of  a  filter  and  of  keeping  the  radium  tube  clean.     In 
a  number  of  cases  it  will  be  possible  to  pass  a  long 
Fig.  245.— Diagram  to  iiius-  flexible  tube  from  the  rectum  through  the  lower 

"~dS;,u*b:IiLt?„t:.  opening  of  a  "Oloto-"/  wound,  when  several  tubes 
bowel.  may  be  introduced,  and  applied  to  the  whole  of 

The  dark  lines  represent  the  canal  affected  by  the  growth.     In  this  way  a 

the  radium  tubes,  the  shaded    , ,  ,  i  n  i    •        i       ,  ,         , 

areas    the    growth.      The  thorough  cxposure  may  DC  Obtained  at  one  treat- 
radium  tubes  are  enclosed  in  ment.     During  the  exposure  the  tube  containing  the 

a  long  rubber  tube.  t  j    i  i  i  i     •  n 

radium  tube  can  be  moved  several  times  upwards 
and  downwards,  so  as  to  ensure  an  equal  distribution  of  the  radiation 
over  the  entire  surface  of  the  growth. 


In  Cancer  of  the  Prostate  Gland 

This  may  be  treated  by  four  methods  : 

(1)  By  the  rectum. 

(2)  By  tubes  introduced  into  the  bladder.  The  tube  is  enclosed  in  a 
catheter. 

(3)  By  a  number  of  tubes  introduced  into  the  substance  of  the  gland. 
The  perineal  route  may  be  employed. 

(4)  Post-operative  treatment.  Tubes  can  readily  be  introduced  into 
the  bladder  after  operation. 

When  treating  by  method  No.  1  radium  should  be  filtered  through 
2  mm.  of  platinum.  Comparatively  long  exposures  may  be  given,  up  to 
twelve  to  fifteen  hours,  using  100  mgrms.  of  radium. 


RADIUM  IN  CANCER  377 

No.  2. — This  does  not  allow  of  very  thick  filters,  therefore  the  exposures 
must  be  reduced  proportionately. 

By  method  No.  3,  provided  the  tubes  can  be  quite  surrounded  by  the 
growth,  comparatively  long  exposures  may  be  given. 

After  complete  removal  of  the  prostate  gland  radium  tubes  should  be 
left  in  the  tissues  at  the  base  of  the  bladder  for  several  hours,  with  thick 
filters,  the  object  of  treatment  in  this  case  being  prophylactic. 

In  Cancer  of  the  Bladder 

If  a  tube  can  be  introduced  into  the  bladder  and  brought  into  contact 
with  the  growth,  relief  may  be  obtained,  and  hasmorrhage  and  discharge 
are  lessened.  In  some  instances  a  marked  improvement  in  the  condition  of 
the  patient  ensues,  and  the  tumour  may  diminish  greatly  in  size.  Simple 
conditions  of  the  bladder  may  also  benefit  from  radium  treatment,  papilloma 
will  be  checked  in  growth,  and  haemorrhage  is  stopped  for  a  time  at  least. 
In  bad  cases  it  is  good  practice  to  combine  X-rays  with  radium.  The  former 
may  be  employed  through  the  abdominal  walls  and  the  perineum. 


C.  THE  COMBINED  USE  OF  RADIUM  AND  X-RAYS  IN 
THE  TREATMENT  OF  MALIGNANT  DISEASE 

In  the  preceding  pages  on  radiation  therapeutics  the  strictly  practical 
aspects  of  the  methods  have  been  rigidly  adhered  to.  Reference  to  cases 
where  success  has  attended  the  treatment  are  given  as  occasion  indicates, 
but  an  expression  of  opinion  as  to  the  value  of  radium  or  X-rays  as  a  curative 
or  specific  agent  has  been  omitted,  the  aim  of  the  book  being  to  give  a 
practical  insight  into  the  methods  of  usage  rather  than  a  speculative  one  of 
value  in  relation  to  curative  effect. 

A  brief  review  of  the  general  experience  of  workers  in  the  new  field  of 
therapy  would  seem  to  be  a  fitting  conclusion  to  the  book,  with  particular 
reference  to  that  aspect  of  the  remedies  on  which  an  opinion  is  so  often 
demanded. 

The  results  obtained  in  the  earHer  days  of  trial  of  these  agents  led  to 
the  expectation  of  enhanced  results  as  experience  grew,  and  methods  of 
technique  were  improved.  These  expectations  have  been  realised  to  some 
extent,  and  there  is  reason  to  hope  that,  with  accumulating  experience  and 
a  more  complete  knowledge  of  the  action  of  radiations  upon  cell  processes, 
further  improvements  may  be  looked  for. 

There  has  been  a  marked  advance  in  the  technique  of  X-ray  therapy, 
which  bids  fair  soon  to  place  X-rays  upon  the  same  footing  as  radium  in  the 
treatment  of  malignant  diseases.  Indeed,  in  the  opinion  of  many  workers, 
including  the  writer,  it  is  probable  that  X-rays  may  soon  prove  to  be  more 
useful  than  radium  as  it  is  at  present  used.  The  factors  which  have  led  to 
this  improvement  are  :  (1)  A  great  advance  in  the  manufacture  of  the  X-ray 
tube,  enabling  much  larger  doses  of  a  more  penetrating  ray  to  be  employed  ; 
(2)  the  employment  of  much  more  powerful  apparatus  which  the  use  of  the 
new  tube  facilitates  ;  (3)  the  use  of  thick  filters  ;  (4)  the  administration  of 
more  powerful  doses  at  more  frequent  intervals. 

A  further  factor  which  has  led  to  improvement  has  been  the  employ- 
ment of  both  agents  together  or  alternately,  radium  being  used  for  the  more 
strictly  local  apphcations,  and  X-rays  for  the  treatment  of  the  more  distant 
parts  which  may  already  be  involved  by  new  growth,  or  may  be  likely  to 
become  invaded  as  a  result  of  the  extension  of  the  disease  by  natural  channels, 
or  as  a  direct  result  of  the  local  stimulation  if  dosage  is  not  correctly  gauged. 

In  the  treatment  of  non-malignant  neoplasms  such  as  fibromata,  the 
treatment  by  X-rays  alone  has  been  attended  with  a  considerable  degree 

378 


COMBINED  USE  OF  RADIUM  AND  X-RAYS  379 

of  success.  The  early  work  of  Continental  investigators  has  stimulated  work 
in  the  same  direction  in  this  country,  and  results  are  now  being  obtained  in 
both  simple  and  mahgnant  neoplasms  which  are  of  very  striking  significance 
in  view  of  what  can  be  done  by  the  older  and  better  recognised  methods  of 
treatment.  In  many  instances  of  fibromata  marked  improvement  follows 
the  initial  series,  and  after  four  or  five  courses  of  treatment  the  condition 
is  reUeved  and  the  patient  restored  to  good  health.  Results  obtained  in 
these  cases  by  radiation  treatment  compare  very  favourably  with  the 
results  attending  operative  measures,  even  when  the  most  favourable  cases 
for  operative  treatment  are  included  in  the  cases  analysed. 

For  malignant  disease  of  the  pelvic  organs,  when  at  all  advanced,  radia- 
tion therapy  holds  out  as  good  a  prospect  as  operative  measures,  especially 
when  the  latter  have  to  be,  as  necessarily  they  must  be,  extremely  radical 
if  a  prospect  of  cure  or  temporary  amehoration  is  to  be  held  out.  It  must 
not  be  assumed,  however,  that  radiation  treatment  holds  out  a  better  prospect 
of  cure.  Recurrences  can  and  do  occur,  with  about  the  same  frequency  as 
after  operation,  and  the  result  will  be  in  both  groups  of  cases  the  same  in 
the  end  ;  but  when  comparing  the  results  consideration  must  be  given  to  the 
condition  of  affairs  existing  in  the  interval  between  the  treatment  and  the 
recurrence.  The  treatment  by  radiations  is  painless,  does  not  subject  the 
patient  to  any  marked  degree  of  shock,  and  the  immediate  effect  is  apparent 
in  an  improvement  in  health,  a  diminution  or  cessation  of  discharge,  and  a 
degree  of  local  comfort. 

It  is  not  intended  to  convey  the  impression  that  treatment  by  X-rays 
or  radium  should  displace  the  operative  in  all  cases ;  far  from  it.  The  ideal 
method  is  to  employ  the  former  in  all  cases  before  operation,  and  again  after 
operation,  the  latter  in  every  case.  Operations  when  performed  should  be 
as  radical  as  possible,  care  being  taken  to  exclude  from  operation  advanced 
cases  where  the  surgeon  knows  that  no  good  can  accrue.  In  these  cases 
X-rays  should  be  employed  as  a  palhative  measure. 

All  cases  of  cancer  of  the  breast  should  receive  prophylactic  treatment 
immediately  after  operation,  and  this  should  be  continued  at  intervals  for 
at  least  a  year. 

A  matter  of  some  importance  from  a  therapist's  point  of  view  in  these 
cases  is  that  no  case,  however  advanced,  should  be  refused  the  trial  of  X-rays 
or  radium.  Some  of  the  most  unfavourable  cases  respond  to  treatment  in 
a  marked  manner,  while  others,  which  appeared  most  favourable  subjects, 
respond  hardly  at  all.  One  case  may  be  quoted.  A  large  superficial  ulcer- 
ated carcinoma  of  the  breast  of  over  a  year's  duration  completely  healed 
up  after  about  six  thorough  radiations.  The  growth  still  exists,  but  it  is 
shrinking  rapidly,  and  in  the  interval  the  patient  enjoys  good  health  and  a 
fair  prospect  of  cure.  This  case  appeared  to  be  most  unsuitable  because 
of  the  large  area  involved. 

The  reason  why  one  case  responds  and  another  fails  to  do  so  is  one  of 
the  profound  problems  which  the  radio-therapist  is  striving  to  fathom, 
and  when  the  solution  is  arrived  at  it  will  go  a  long  way  to  estabhsh 


380  KADIATION  THEEAPEUTICS 

radiation  treatment  on  a  sound,  intelligible  basis.  In  all  probability  tlie 
explanation  is  a  biological  one,  a  condition  of  cell,  physical  or  other,  which 
responds  to  a  particular  type  of  ray,  producing  far-reaching  metabolic  changes 
in  cells  and  sera  which  act  on  tissues  near  and  distant  proportionately. 
The  biological  factor  is  one  which,  in  the  absence  of  convincing  experimental 
evidence,  had  better  be  for  the  present  left  alone,  as  only  speculative 
conjecture  fittingly  describes  any  attempt  to  explain  it.  Future 
attempts  to  clear  up  this  point  will  no  doubt  be  confined  to  physical 
experiments  in  the  direction  of  producing  effects  on  the  deep  tissues,  and 
to  the  interpretation  of  biological  effects  by  experiments  in  immunity 
conferred  on  tissues  by  the  use  of  irradiated  tumours  and  sera  trans- 
planted or  injected.  These  experiments  are  being  actively  carried  out  by 
many  workers. 

The  important  point  from  the  practical  radio-therapeutic  point  of  view 
is  to  determine  the  depth  at  which  a  tissue  can  be  influenced,  and  the  dose  it 
is  possible  to  convey  at  a  particular  depth  of  tissue.  When  these  points  are 
ascertained  it  should  be  possible  to  produce  changes  in  deep  tissues.  Much 
experimental  work  has  already  been  done,  and  an  attempt  is  now  made  to 
summarise  some  of  these  experiments. 

Professors  Bumm  and  Wernekros  of  Berlin  have  published  a  number 
of  experiments  which  in  the  aggregate  confirm  the  observations  of  the  writer, 
who  has  been  experimenting  on  similar  lines  for  several  years.  Up  to  quite 
recently  it  has  been  held  that  X-rays  penetrated  successfully  to  a  depth  of 
about  1  centimetre  or  less,  and  anything  deeper  than  that  has  been  left  alone. 
The  use  of  radioactive  bodies  led  to  the  belief  that  when  employing  the 
Gamma  ray  a  much  greater  depth  could  be  reached,  and  effects  produced  by 
its  use  which  were  unattainable  by  X-rays.  Increasing  experience  leads 
in  the  opposite  direction,  for,  by  using  hard  tubes  and  long  exposures  of 
X-rays,  effects  can  be  produced  as  deep  as  10  cm.,  and  those  of  quite 
a  marked  degree.  The  same  results  may  be  obtained  from  the  use  of 
radioactive  bodies  if  the  quantities  are  large  and  the  time  of  exposure  is 
prolonged  enormously,  too  long  for  safety  so  far  as  the  tissues  in  immediate 
contact  with  the  source  of  irradiation  are  concerned. 

The  X-ray  tube  produces  many  thousand  times  more  rays  than  any 
available  quantity  of  radium,  while  it  is  possible  to  work  at  a  greater 
distance  from  the  skin  or  mucous  surfaces  (a  measure  of  safety  being  thus 
introduced),  and  at  the  same  time  produce  an  effect  on  the  deeper  tissues 
which  is  beyond  all  possible  comparison  with  that  of  the  radioactive  bodies 
even  when  the  Gamma  ray  of  radium  alone  is  used. 

Wernekros  and  others  have  conducted  experiments  which  appear  to 
prove  this  contention  beyond  any  doubt.  With  a  Kienbock  strip  placed  in 
tissues  or  organs  at  a  depth  of  several  centimetres  and  the  surface  of  the  body 
radiated  with  an  X-ray  bulb,  in  ten  minutes'  exposure  10  X  have  been 
recorded  on  the  paper.  With  a  long  radiation  of  200  mgrms.  of  mesothorium 
applied  to  the  skin  no  effect  is  recorded  on  the  paper,  while  in  time  the  skin 
surface  showed  marked  reaction.     These  points  have  been  experimentally 


COMBINED  USE  OF  RADIUM  AND  X-RAYS  381 

proved  by  using  an  electroscope  Und  the  iontoquantimeter  of  Szillard,  and 
have  been  confii'med  on  the  living  tissues. 

It  has  been  suggested  that  radium  and  mesothorium  possess  a  qualitative 
difference  over  the  hard  Rontgen  rays,  and  that  the  Gamma  ray  has  not  only 
a  greater  penetration  but  also  a  more  intense  biological  action,  also  that 
the  Gamma  ray  possesses  a  selective  action  upon  cancer  cells  ;  but  this  has 
never  been  proved  conclusively,  and  in  another  part  of  the  book  the  writer 
calls  attention  to  the  point  that  in  many  cases  it  may  be  a  less  penetrat- 
ing ray  which  is  required  to  produce  a  biological  effect  on  a  particular  type 
of  cell.  In  fact,  the  whole  range  of  rays  may  be  useful  from  the  soft  Rontgen 
ray  to  the  Gamma  ray  of  radium,  and  each  of  these  rays  may  be  required 
when  a  number  of  cases  are  treated.  "  A  "  may  suit  one  case  while  "  Z  " 
may  be  necessary  for  another,  and  so  on. 

The  penetrating  power  of  the  ray  is  only  one  factor.  The  quantity  of 
rays  administered  is  probably  more  important.     It  would  appear  in 

all  cases  of  cancer  which  are  likely  to  benefit  from  X-rays,  it  is  more  a 
question  of  the  quantity  of  rays  which  can  be  administered,  while  with  the 
present  apparatus  at  our  command  the  quality  of  the  ray  may  be  kept  at  a 
fairly  constant  value. 

It  is  now  possible  to  state  in  a  number  of  cases,  according  to  depth  of 
tissue,  what  quantity  of  radiation  may  be  required  to  produce  a  favourable 
result ;  thus,  at  a  depth  of  2  cm.  of  growth  300  to  500  X  may  be  necessary 
to  cause  a  retrogressive  change  in  the  cancer  cells.  The  maximum  depth  in 
any  part  of  the  body  may  be  taken  as  10  cm.  or  at  the  most  15  cm.,  for  if  a 
tumour  exists  in  a  deep  part  of  the  body  it  can  be  and  is  radiated  from  two 
or  more  aspects.  In  order  to  induce  a  therapeutic  effect  at,  say  10  cm., 
the  intensity  diminishing  inversely  as  the  square  of  the  distance,  the  deeper 
parts  receive  about  ^  of  the  total  exposure,  so  that  to  obtain  a  dose  of,  say 
500  X  at  10  cm.,  3500  X  is  required  on  the  skin  surface.  It  is  necessary 
therefore  to  exercise  great  care  in  the  administration  of  these  large  doses. 
Specially  hard  rays  must  be  employed  at  a  sufficiently  great  distance  from 
the  skin  to  avoid  doing  harm  to  that  structure.  To  produce  such  effects 
some  risk  must  be  taken,  and  in  the  experience  of  many  workers  on  these 
lines,  radiodermatitis  has  been  produced  and  must  be  acknowledged.  At 
the  present  time,  so  far  as  we  know,  these  risks  have  been  minimised,  and 
the  difficulties  which  lead  to  their  occurrence  have  been  overcome. 

The  points  therefore  to  observe  in  order  to  get  in  these  heavy  doses  of 
penetrating  rays  are:  (1)  employment  of  thick  filters,  (2)  the  distance 
from  the  skin  and  the  use  of  accessory  filters  of  various  substances,  (3) 
many  ports  of  entry,  (4)  sufficiently  long  intervals  between  the  exposures. 
So  far  we  have  been  able  to  demonstrate  that  radiations  exercise  an 
influence  on  tissue  change,  and  that  it  is  often  a  matter  of  selection  of  ray ; 
so  we  may  assume  that  in  the  treatment  of  deep-seated  growths  X-rays  and 
radium  should  be  combined  because  of  the  wider  area  which  can  be  treated, 
and  the  ease  with  which  radium  can  be  applied  to  regions  where  X-rays 
are  not  easily  applied  ;  thus,  a  rectal  cancer  can  be  treated  locally  by  radium, 


382  EADIATION  THEKAPEUTICS 

while  from  tlie  skin  surface  it  may  be  attacked  by  X-rays  from  the  anterior 
abdominal,  the  posterior,  and  the  perineal  route.  Using  a  good  quantity 
of  radium  and  a  penetrating  X-ray,  the  resulting  influence  over  the  growth 
and  glands  must  be  enormously  enhanced.  The  X-ray  exposures  may  be 
carried  on  in  the  intervals  between  the  radium  exposures. 

Similarly  in  carcinoma  of  the  uterus,  whether  of  the  cervix  or  fundus, 
the  cancer  may  be  vigorously  treated  after  the  technique  of  Freiburg  by 
X-rays  and  radium  introduced  into  the  uterus.  In  these  tumours  frequent 
seances  of  heavy  doses  lead  to  marked  effects.  Many  cases  might  be 
quoted  where  improvement  to  a  marked  degree  has  resulted.  Tissue  changes 
can  be  studied  in  sections  removed  during  the  course  of  treatment,  and  all 
show  the  typical  degenerative  processes  seen  in  such  cases,  which  are 
described  and  illustrated  in  pages  256-261. 

Carcinoma  of  the  Mammw. — The  result  of  very  heavy  dosage  in  nearly 
all  forms  of  this  disease  is  beneficial.  Growths  diminish  in  size,  ulcerated 
surfaces  heal,  and  the  general  health  improves.  It  is  necessary  to  push 
the  treatment.  The  skin  is  divided  into  squares,  and  doses  given  at  regular 
intervals.  Each  square  may  receive  300  to  800  X  or  more  altogether 
during  the  treatment,  which  is  spread  over  several  months. 

There  may  be  some  skin  reaction,  but  when  dealing  with  bad  cases  this 
must  not  be  regarded  as  a  deterrent.  Bumm  quotes  several  cases  which 
derived  great  benefit.  From  an  extensive  experience  in  the  treatment  of  this 
form  of  cancer  the  writer  feels  convinced  that  in  the  later  cases  treated,  where 
very  heavy  doses  have  been  administered,  the  results  show  a  marked  improve- 
ment on  the  earlier  cases,  where  the  treatment  was  not  so  thorough.  Large 
primary  growths  slowly  diminish  in  size,  recurrences  clear  up,  and  the 
patient  receives  great  benefit.  In  these  cases  the  X-ray  treatment  is  to  be 
preferred  to  radium  for  reasons  aheady  stated.  It  is,  however,  important 
that  a  thorough  technique  be  undertaken. 

In  the  treatment  of  cancer  of  the  breast  in  comparatively  young  subjects 
from  thirty  to  thirty-five  years  of  age,  it  is  often  noticed  that,  however  early 
and  radical  the  operation  may  have  been,  recurrence  takes  place  early,  and 
very  little  success  attends  whatever  form  of  treatment  is  employed.  X-rays 
and  radium  are  no  exceptions  to  this  rule. 

The  explanation  of  this  marked  degree  of  virulence  is  obscure,  and  it  is 
difficult  to  suggest  measures  which  may  control  the  progress  of  the  disease. 
Such  radical  operations  as  double  oophorectomy  have  been  employed,  but 
without  any  great  measure  of  success.  Nevertheless  the  activity  of  the 
ovaries  may  affect  the  morbid  process,  as  presumably  at  this  early  age  all 
the  tissues  are  in  a  state  of  full  activity,  and  no  doubt  the  new  growth 
participates  to  a  varying  degree  in  this,  and  quickly  spreads  to  the  adjacent 
lymph  and  other  structures.  It  is  also  well  recognised  that  the  most  favour- 
able cases  for  any  form  of  treatment  occur  in  patients  at  or  after  the  meno- 
pause, when  atrophic  cancer  is  often  met  with. 

Instead  of  oophorectomy  a  method  of  treatment  by  radiations  is  here 
suggested.     In  addition  to  the  local  post  operative  treatment  the  ovarian 


COMBINED  USE  OF  RADIUM  AND  X-RAYS  383 

areas  should  be  thoroughly  treated  by  several  series  of  exposures  until  a 
temporary  menopause  is  produced,  following  the  Freiburg  technique. 

Mediastinal  Cancer. — In  this  condition,  which  is  frequently  met  with, 
a  large  field  exists  for  the  use  of  X-rays.  This  also  applies  to  cases  of  sarcoma, 
lympho-sarcoma,  and  recurrent  cancer  of  the  lungs  and  pleura.  The  chest 
is  mapped  out  in  squares,  anteriorly,  posteriorly,  and  laterally,  and  each 
area  is  treated  to  the  maximum  extent  at  regular  intervals.  In  this  way  it 
is  possible  to  get  in  doses  of  several  thousand  X  in  a  comparatively  short  time. 
There  is  every  hope  that  with  such  thorough  treatment  a  marked  advance 
in  the  treatment  of  cancer  will  ensue.  Certainly  all  patients  should  be  given 
the  opportunity  of  benefiting  by  this  advanced  method. 

The  administration  of  these  intensive  doses  involves  a  great  deal  of  time. 
Many  cases  will  take  six  to  eight  hours  for  each  series  of  exposures,  and  this 
entails  a  heavy  wear  and  tear  on  apparatus.  Such  efficient  treatment  can 
only  be  carried  out  successfully  in  hospitals  and  nursing-homes  where  the 
patients  can  be  kept  for  hours  under  close  observation. 

From  the  study  of  a  number  of  sections  removed  at  different  stages  in 
the  treatment  of  cases  of  cancer,  it  may  be  recorded  that  marked  changes 
are  induced  in  the  tumour  cells.  These  include  :  (1)  enlargement  of  the 
nucleus,  with  increased  subdivision ;  (2)  increase  of  fibrous  tissue  ;  (3) 
gradual  disappearance  of  the  cancer  cells  in  the  fibrous  tissue  matrix.  Con- 
stitutional symptoms  are  also  induced  by  this  heavy  radiation  treatment. 
These  are  similar  to  those  produced  by  radium  treatment,  and  include  a 
period  of  marked  depression,  lassitude,  etc.  Sickness  may  come  on  a  few 
days  after  the  treatment.  The  patient  should  be  kept  quietly  in  bed  for 
a  few  days  on  a  generous  diet. 

The  accumulation  of  experience  in  the  treatment  of  malignant  disease 
serves  to  demonstrate  that  in  these  comparatively  new  agents  we  possess  a 
therapeutic  factor  which  has  great  influence  on  cell  growth,  morbid  or 
normal.  The  exact  degree  of  influence  is  difficult  to  estimate  because  of  the 
remarkable  inequality  of  the  action  upon  various  tissues,  and  particularly 
upon  the  products  of  tumour  invasion.  The  administration  of  a  large  dose 
of  radiations  upon  the  products  of  inflammation  often  leads  to  a  diminution 
of  the  process  and  in  time  to  a  return  of  the  tissues  to  normal.  The  same 
intensity  and  quantity  of  radiation  applied  to  a  tissue  growth  of  mildly 
mahgnant  character  may  lead  to  a  diminution  of  the  growth  and  of  the 
malignant  process,  and  a  return  to  the  normal  or  to  the  formation  of  a  mass 
of  fibrous  tissue  which  no  longer  exhibits  the  characteristics  of  a  new  growth. 
Histological  investigation  of  such  a  mass  will,  however,  frequently  show 
cancer  cell  remnants  in  parts  of  the  fibrous  tissue.  These  remnants  are 
still  capable  of  recrudescence,  and  are  liable  to  resume  activity  at  a 
later  date.  The  existence  of  these  remnants  is  therefore  a  source  of  danger 
to  the  patient,  and  with  such  patients,  when  all  has  been  accomplished  that 
radiations  can  achieve,  the  question  of  operation  must  be  kept  well  to  the 
fore.  The  danger  of  lighting  up  a  cancerous  process  by  operation  in  these 
cases  is  lessened  when  the  patient  has  been  thoroughly  treated  by  rays, 


384  RADIATION  THERAPEUTICS 

because  of  tlie  obvious  fact  that  a  marked  degree  of  fibrous  tissue  formed 
in  and  around  the  new  growth  diminishes  the  danger  of  a  rapid  spread  if  an 
operation  is  performed.  This  is  also  a  strong  argument  in  favour  of  treat- 
ment before  operation,  because,  if  it  is  thorough,  the  probabihty  is  that  the 
formation  of  fibrous  tissue  wide  of  the  growth  will  tend  to  prevent  the 
spread  of  the  infected  cells  at  the  time  of  the  operation.  Should  such  cells 
exist  at  the  time  of  treatment  it  is  probable  that  they  are  damaged  by  the 
radiations,  and  are  no  longer  violently  infective.  Similarly,  after  operation, 
should  any  infected  tissue  remain,  the  reactive  processes  set  up  in  the  tissues 
may  lead  to  the  inclusion  of  these  in  fibrous  tissue,  and  the  subsequent 
degeneration  of  the  cells  lead  to  a  lessening  of  their  activity. 

The  subsequent  course  of  patients  so  treated  is  being  watched  with  great 
interest.  Is  it  possible  to  prevent  recurrence  and  confer  upon  the  patient 
a  period  of  comparative  immunity  ?  The  early  recurrence  of  a  neoplasm 
after  radiation  treatment  does  not  necessarily  prove  that  the  treatment 
taken  as  a  whole  is  of  no  value.  It  merely  demonstrates  that  we  have  not 
given  a  dose  sufficient  to  check  the  particular  malignant  process  in  activity 
in  the  case.  It  must  also  be  borne  in  mind  that  there  are  growths  which 
cannot  be  influenced  by  any  radiations  at  present  at  our  command.  It 
would  appear  that  these  cases  are  quite  as  irresponsive  to  any  other  form  of 
treatment.  Complete  radical  excision  of  a  comparatively  early  growth, 
with  apparently  no  involvement  of  glands,  is  followed  by  a  complete  recovery. 
Later,  but  in  these  cases  comparatively  soon  after  operation,  recurrence 
shows  itself  in  the  scar  or  neighbouring  lymphatic  glands.  No  subsequent 
treatment  appears  to  do  any  good.  Radiation  treatment  in  a  case  of  this 
type  would,  however  early  and  thorough  the  treatment  might  be,  achieve 
no  better  result. 

It  is  the  less  virulent  case  which  is  more  amenable  to  both  methods  of 
treatment.  The  choice  of  treatment  in  these  cases  raises  a  wide  and  difficult 
question.  Which  of  the  two  methods  promises  the  better  result  ?  In  the 
present  state  of  our  knowledge  of  radiation  therapeutics,  in  the  great  un- 
certainty of  action  upon  particular  types  of  tumours,  the  preference  must 
be  given  to  early  operation,  which  should  be  as  thorough  as  possible  and 
should  be  followed  by  X-ray  treatment. 

The  following  conclusions  on  the  value  of  X-rays  and  radium  in  the 
treatment  of  malignant  disease  can  be  drawn  : 

(1)  These  agents  are  most  valuable  aids  to  the  treatment  of  these  con- 
ditions in  so  far  as  by  their  use  we  can  induce  changes  in  tumours  which  are 
unattainable  by  any  other  agent  at  present  in  use. 

(2)  X-rays  and  radium  may  be  used  separately  or  combined  in  the  same 
case,  and  in  some  instances  it  is  advantageous  to  alternate  the  use  of  the 
two. 

(3)  In  so  far  as  it  is  possible  to  demonstrate  profound  changes  in  in- 
operable growths  of  large  size,  it  is  a  logical  conclusion  to  arrive  at  that 
cancer  tissue  of  small  size  left  at  the  time  of  operation  may  by  post-operative 
treatment  be  rendered  inert,  and  recrudescence  of  growth  be  prevented. 


COMBINED  USE  OF  RADIUM  AND  X-RAYS  385 

It  is  therefore  sound  policy  to  insist  on  post-operative  treatment  in  all 
cases  submitted  to  operation.  The  post-operative  treatment  must  be  carried 
out  with  as  complete  thoroughness  as  when  we  are  attempting  to  induce  the 
resolution  of  a  growth  of  considerable  size. 

When  a  thorough  course  of  treatment  has  been  apphed  the  patient 
should  be  instructed  to  come  at  intervals  for  inspection,  and  if  necessary 
for  more  treatment  for  two  or  three  years  after  the  operation. 

(4)  Other  methods  of  treatment  must  not  be  neglected  when  the  radia- 
tions are  being  used.  Thus,  it  may  be  advisable  to  remove  growths  which 
appear  to  be  arrested  or  which  are  not  yielding  to  treatment.  This  will 
greatly  aid  in  the  administration  of  radiations  and  lead  to  an  improvement 
in  results.  Drugs  which  are  known  to  aid  the  action  of  radiations  should  be 
used.  Thyroid  extract  is  known  to  exercise  a  far-reaching  effect  upon  tissue 
metabolism.  Pfahler  of  Philadelphia  recommends  the  administration  of 
thyroid  extract  in  nearly  all  cases  submitted  to  radiations.  Iron,  arsenic, 
and  in  some  cases  salvarsan  may  be  used  as  aids  to  treatment  by  radiations. 
In  several  cases  which  have  had  the  latter  drug  administered,  rapid  changes 
have  been  induced  in  the  blood  and  tissues  by  radiations  administered 
subsequent  to  the  drug. 

In  conclusion,  it  may  be  stated  that  in  all  probabihty  the  treatment 
of  malignant  disease  by  radiations  is  not  nearly  so  efficient  as  it  may  be  in 
the  future.  With  advancing  knowledge,  improvements  in  apparatus  and 
technique,  and  a  more  perfect  understanding  of  the  tissue  reaction  to 
radiations,  there  is  every  hope  that  in  the  near  future  a  great  advance  in 
results  will  be  attained. 


25 


GLOSSARY 

Accumulator.     A  secondary  or  storage  battery. 

Actinic  Eay.  A  ray  of  light  or  other  form  of  radiant  energy  capable  of  producing 
chemical  action. 

"  Alive."     A  wire  is  said  to  be  aUve  when  an  electric  current  is  passing  along  it. 

Alternating  Current.     Cxirrents  whose  directions  are  periodically  reversed. 

Ammeter  or  Amperemeter.  Any  form  of  galvanometer  which  is  capable  of 
measuring  current  strength  in  amperes. 

Ampere.  Unit  of  strength  of  the  electric  current,  exerted  by  an  electromotive  force 
of  one  volt  through  a  resistance  of  one  ohm. 

Anode.     The  positive  pole  of  an  electric  battery  or  the  electrode  cormected  with  it. 

Anticathode  of  X-Ray  Tube.  A  plate  of  platinum  or  other  metal,  supported 
inside  an  X-ray  tube  upon  which  the  cathodic  stream  impinges. 

Aperiodic  Galvanometer.  A  galvanometer  whose  needle  comes  to  rest  without 
oscillations. 

Armature.     A  coil  of  wire  made  to  cut  the  lines  of  force  from  the  field  magnets. 

Automatic  Cut-Out  or  Switch.  A  device  for  automatically  cutting  o2  the  current 
at  any  predetermined  period  of  time  by  means  of  a  time  relay. 

Battery.     Apparatus  for  the  production  of  an  electromotive  force. 

Blowing  a  Fuse.  The  melting  of  a  wire  by  the  passage  of  an  electric  current 
through  it. 

Break  (noun),  (a)  An  instrument  for  periodically  interrupting  a  circuit ;  (&)  any 
interruption  in  an  electric  wire. 

Break  (to — verb).     To  interrupt  an  electric  circuit  as  opposed  to  closmg  the  circuit. 

B.T.U.     Board  of  Trade  unit  =  1000  watt-hours. 

Buckling.     The  disintegration  of  the  surface  of  the  plates  of  a  storage  battery. 

Calibrate.  To  determine  the  absolute  values  of  scale  divisions  of  an  electrical 
instrument  such  as  a  galvanometer,  voltmeter,  wattmeter,  etc. 

Candle  Power.  The  intensity  of  light  emitted  by  a  luminous  body  estimated  in 
standard  candles. 

Capacity  of  Condenser.  The  quantity  of  electricity  a  condenser  is  capable  of 
holding  in  coulombs  when  charged  to  a  pressure  of  one  volt. 

Cathode.  The  negative  pole  of  an  electric  battery,  or  the  electrode  connected 
with  it. 

Cathode  Eays.  Rays  originating  in  a  vacuum  tube  at  the  negative  terminal,  when 
a  discharge  of  electricity  is  passed  through  the  tube.  They  are  not  identical  with  the 
Rontgen  rays,  since  they  are  deviable  by  a  magnet  and  by  refracting  media,  and  are 
rapidly  absorbed  by  opaque  bodies  and  by  the  atmosphere. 

Circuit.     A  term  employed  to  denote  the  total  electrical  path  of  an  installation. 

Commutator,  Current  Eeverser.  An  apparatus  for  reversing  the  direction  of  the 
current. 

Condenser.     An  apparatus  for  storing  a  large  amount  of  electricity. 

Conductor.  Any  substance  which  conducts  or  possesses  the  power  of  conducting 
electricity. 

Continuous  Current  (also  called  Direct).  A  current  whose  direction  is  constant, 
as  distinguished  from  alternating  current. 

387 


388  EADIOGEAPHY 

Coulomb.  Is  that  amount  of  electricity  which  is  carried  by  an  ampere  flowing 
for  one  second  past  any  given  point  in  the  circuit.  There  are  3600  coulombs  in  one 
ampere-hour. 

Current  Strength.  In  a  direct-current  circuit  the  quotient  of  the  total  electro- 
motive force  divided  by  the  total  resistance,  or  C  =  5. 

Current  Transformer,  (a)  An  instrument  for  changing  an  alternating  into  a  direct 
current,  or  vice  versa  ;  (6)  a  device  for  altering  the  pressure  of  a  current,  which  may  be 
either  a  step-up,  i.e.  raises  the  pressiure,  or  a  step-down  transformer,  i.e.  lowers  the 
pressure. 

Dead-Beat  Galvanometer.  A  galvanometer  whose  needle  comes  quickly  to  rest 
instead  of  repeatedly  swinging  to  and  fro,  through  being  heavily  damped. 

Dielectric.  Any  material  which  offers  high  resistance  to  the  passage  of  an  electric 
current. 

Difference  of  Potential.  When  electricity  moves,  or  tends  to  move,  from  one  point 
to  another,  there  is  said  to  be  a  difference  of  potential  between  them. 

Discharge.  The  disruptive  passage  of  electric  current  when  opposite  polarities 
approximate,  or  a  sudden  equalisation  of  potentials. 

Dynamo.  A  machine  for  the  conversion  of  mechanical  energy  into  electrical 
currents  by  means  of  electro-magnetic  induction. 

Dyne.  The  unit  of  force,  i.e.  the  force  which,  if  it  acted  for  1  second  on  a  mass  of 
1  gramme,  would,  if  the  mass  were  previously  at  rest,  give  it  a  velocity  of  1  centimetre 
per  second. 

Electric  Efficiency.  The  ratio  between  the  amount  of  current  generated  and  the 
expenditure  required  to  produce  it. 

Electroscope.  An  apparatus  for  detecting  the  presence  of  an  electric  charge  or 
determining  its  polarity. 

E.M.F.     Electromotive  force.     The  force  exerted  by  an  electrical  charge. 

Erg  {ergon,  work).  The  unit  of  work.  It  is  that  which  is  effected  in  raising 
1'981  gm.  to  the  height  of  1  centimetre. 

Farad.     The  practical  unit  of  electric  capacity. 

Fault.     Any  defect  in  the  proper  working  of  a  circuit. 

Field  (Magnetic).     The  space  about  a  magnet  through  which  its  influence  is  active. 

Filtration  of  X-Eays.  Placing  in  the  path  of  the  rays  some  medium  such  as 
aluminium  or  felt,  in  order  to  absorb  some  of  the  softer  radiation. 

Fluorescent  (fluoroscopic)  Screen.  A  screen  covered  with  fluorescent  material, 
which  permits  the  visual  examination  of  the  human  body  by  means  of  X-rays. 

Fuse  (Safety).  A  soft  metal  wire  interposed  in  a  circuit,  which  will  melt  if  a, 
current  too  strong  for  safety  passes  through  it. 

Gap-Spark.     The  space  between  the  terminals  of  two  conductors. 

Hard.  Hard  and  soft  are  terms  applied  to  X-ray  and  other  vacuum  tubes  ;  they 
refer  to  the  relative  completeness  of  the  exhaustion  therein  of  the  retained  air  or  residual 
gas.     A  hard  tube  has  a  higher  resistance  than  a  low  or  soft  tube. 

Henry.  An  electrical  unit  of  inductance  equal  to  the  inductance  of  a  circuit  when 
the  electromotive  force  induced  in  it  equals  1  volt  when  the  exciting  circuit  varies  at 
the  rate  of  1  ampere  per  second. 

Hot-Wire  Meter.  A  meter  whose  readings  are  based  on  the  expansion  of  a  wire, 
due  to  an  increase  of  temperature,  by  the  passage  through  it  of  the  current  that  is  to 
be  measured. 

Hysteresis.  A  term  applied  to  residual  effects  in  the  rapid  magnetisation  and 
demagnetisation  of  a  soft  iron  core  lying  within  a  coil  of  insulated  wire,  through  which 
an  interrupted  constant  current  is  flowing. 

Induced  Current.  That  secondary  current  produced  by  induction.  It  flows  in 
the  opposite  direction  to  the  primary  or  inducing  current  when  the  latter  is  made,  but 
in  the  same  direction  when  it  is  broken. 

Induction  Coil.  An  apparatus  consisting  of  two  associated  coils  of  insulated  wire 
employed  for  the  production  of  currents  by  mutual  induction. 


GLOSSARY  389 

Insulator.     A  non-conductor  or  a  bad  conductor,  e.rj.  glass,  rubber,  shellac. 

Intensifying  Screen.  A  surface  coated  with  some  fluorescing  material,  such  as 
tungstato  of  calcium,  placed  in  contact  with  the  film  side  of  the  X-ray  plate  ;  the  time 
necessary  for  exposure  is  materially  shortened. 

Inverse  Current.  The  current  produced  in  the  secondary  of  an  induction  coil  on 
the  making  or  completion  of  the  circuit  of  the  primary.  Inverse  currents  flow  in  the 
opposite  direction  to  the  original  current. 

Joule.  The  amount  of  energy  employed  in  maintaining  a  current  of  1  ampere  for 
1  second  against  a  resistance  of  1  ohm — 10,000,000  ergs. 

Kilowatt.     1000  watts. 

Micro-Farad.     Practical  unit  of  capacity. 

Milliampere.    xoVo  °^  ^"^  ampere. 

Milliamperemeter.  An  instrument  for  recording  the  strength  of  a  current  passing 
in  fractions  of  an  ampere. 

Ohm.  Practical  unit  of  electrical  resistance.  It  was  decided  (Paris  Congress, 
1884)  that  the  legal  ohm  is  the  resistance  offered  by  a  column  of  mercury  106  cm.  high, 
1  square  mm.  in  cross-section,  having  about  the  resistance  of  100  metres  of  telegraph 
wire. 

Ohm's  Law.  The  strength  of  the  current  varies  directly  as  the  E.M.F.  and  inversely 
as  the  resistance  of  the  circuit,  or  the  current  expressed  in  amperes  is  equal  to  the 
E.M.F.  expressed  in  volts  divided  by  the  resistance  expressed  in  ohms : 

The  law  was  enunciated  by  Dr.  G.  S.  Ohm,  and  is  used  for  showing  the  relation  between 
Electromotive  Force,  Resistance,  and  Current. 

Oscilloscope.  A  vacuum  tube,  constructed  so  as  to  show  whether  a  current  is 
unidirectional  or  oscillatory,  and  in  the  latter  case  roughly  in  which  direction  the  greater 
quantity  of  current  is  flowing. 

Parallel.  Cells  are  said  to  be  parallel  when  the  positive  elements  are  all  connected 
to  each  other,  and  the  negative  are  similarly  connected.  The  E.M.F.  is  only  equal  to 
the  E.M.F.  of  one  cell,  but  its  internal  resistance  is  diminished  in  proportion  to  the 
number  of  cells  thus  joined.     See  Series. 

Pole  Tester.  Any  device  for  readily  determining  the  polarity  of  the  current,  e.g. 
wet  blue  litmus  paper  will  turn  red  in  contact  with  the  positive  pole  from  a  galvanic 
battery  ;  the  red  spot  will  become  blue  again  on  the  application  of  the  negative  pole  ; 
or  when  the  end  tips  are  placed  in  water  and  a  galvanic  current  is  turned  on,  bubbles  of 
hydrogen  will  rise  from  the  negative  side,  while  the  positive  tip  will  become  blackened. 

Potential  =  ^oie??.fo'a,  power,  ready  to  act,  but  not  yet  acting).  It  is  the  condition 
of  electrical  tension  of  a  body.  This  term  holds  the  same  relation  to  electricity  that  the 
term  level  does  to  gravity  ;  just  as  water  at  a  higher  level  tends  to  move  to  a  point  of 
lower  level,  so  does  the  accumulation  of  electric  energy,  at  that  point  in  the  circuit  at 
which  it  is  present  in  excess  over  any  other  point  in  the  circuit,  tend  to  seek  that  point 
in  the  circuit  at  which  it  is  lowest,  so  that  electrical  equilibrium  may  be  restored. 

Radium  Definitions  : 

1  Curie,  quantity  of  radium  emanation  (0-60  cubic  milhmetres  at  0°  C.  and  760  mm. 
pressure)  in  equilibrium,  with  1  gramme  of  radium  element. 

This  quantity  gives  a  saturation  current  in  an  ionisation  chamber  of  indefinite 
dimensions,  of  2-67  miUion  electrostatic  units  (0-89  milHampere).  One  curie  of  emana- 
tion per  litre  would  equal  a  concentration  of  2670  milHon  Mache  units. 

1  Millicurie,  quantity  of  radium  emanation  in  equilibrium  with  1  milligramme 
(one-thousandth  of  a  gramme)  of  radium  element. 

1  Microcurie,  quantity  of  radium  emanation  in  equilibrium  with  1  microgramme 
(one-millionth  of  a  gramme)  of  radium  element.  One  microcurie  per  Htre  equals  a  con- 
centration of  about  2700  Mach6  units. 

1  Milligramme-minute,  quantity  of  radium  emanation  produced  in  1  minute  by 
1  milligramme  of  pure  anhydrous  radium  bromide.  This  quantity  is  0-073  microcurie, 
and  would  give  per  litre  a  concentration  of  about  180  Mach6  units. 

1  Electrostatic  unit  (E.S.U.),  current  measure  3-33  x  10-iO(0-000000000333)  ampere. 


390  EADIOGKAPHY 

1  Mache  unit  (M.U.)j  saturation  ionisation  current,  due  to  radium  emanation  from 
a  litre  of  solution  of  gas  expressed  in  electrostatic  units  multiplied  by  1000. 

Ray,  Rontgen  or  X.  Rays  emitted  from  the  soiirce  of  radiant  energy  excited  by  a 
discharge  of  electricity  within  a  vacuum  tube,  not  deviable  by  a  magnet  or  refracting 
medium  ;  they  pass  through  opaque  bodies,  cause  certain  substances  to  fluoresce,  affect 
a  photographic  plate  like  Ught  rays,  and  they  have  pecuUar  effects  upon  living  tissue, 
normal  and  pathological. 

Rectifier.  An  apparatus  which  is  used  to  transform  an  alternating  current  into 
what  is  practically  a  unidirectional  current.  There  are  several  kinds  of  rectifiers,  the 
simplest  of  which  is  the  "  aluminium  cell." 

Resistance,  (a)  That  which  opposes  the  current  flow.  (6)  The  ratio  of  E.M.F.  to 
the  current  strength  :  „     e 

Rheostat.     An  instrument  for  regulating  the  resistance  of  an  electric  current. 

Rotary  Converter.  A  machine  similar  in  design  to  an  ordinary  continuous  current 
generator,  but  provided  with  shp  rings,  connected  to  suitable  points  in  the  armature 
winding. 

Sabouraud's  Pastilles.  Pastilles  of  Ught-green  colour,  called  by  Sabouraud  tint  A, 
which  turned  to  an  orange  colour,  called  by  Sabouraud  tint  B,  on  being  exposed  to 
X-rays,  thus  measuring  the  dose. 

Self-induction.  Induction  produced  in  a  circuit  by  the  induction  of  a  current  on 
itself  at  the  make  or  break  of  the  current  therein. 

Series.  Cells  are  said  to  be  in  series  when  the  positive  element  of  one  cell  is  con- 
nected with  the  negative  element  of  the  next  cell,  and  so  on.  The  electromotive  force 
of  the  combination,  measured  from  the  positive  pole  of  the  first  to  the  negative  pole  of 
the  last,  is  thus  increased,  e.g.  in  a  battery  with  three  cells,  each  having  an  E.M.F.  of 
1-5,  the  total  E.M.F.  will  be  volt  4-5. 

Supply,  Unit  of.     Board  of  Trade  unit. 

Unit  Megohm.     1,000,000  ohms. 

Unit  Micro-Farad,     lopo.oou  farad. 

Unit  Micro-Volt,    f^^i^o  '^°^*- 

Unit  Milliampere.     ywoo  ai^pere. 

Vacuum  Tube.  Glass  tubes  or  bulbs  from  which  nearly  all  traces  of  gas  have  been 
removed. 

Volt.  The  practical  unit  of  E.M.F.  An  E.M.F.  which  would  cause  a  current  of 
1  ampere  to  flow  through  a  resistance  of  1  ohm. 

Voltmeter.     An  instrument  for  measuring  difference  of  potential. 

Watt.     Is  a  volt-ampere,  or  unit  of  electrical  force. 

Zero  Potential.     The  earth's  potential. 


INDEX 

Numerals  in  italics  indicate  that  there  are  illustrations  on  those  pages.     A  full-page 
plate  is  indicated  by  the  letter  P.  followed  by  the  number  of  page  at  which  it  appears. 


Abscess  of  the  lung,  203,  204 

Accessories  for  tube-stands  (see  Tube-stands) 

Accumulator  connections,  11 

Acetabulum,  injury  to,  165 

Achrondroplasia,  172 

Acne  vulgaris,  treatment  by  X-rays,  304 

Actinomycosis  of  lung,  202 

Adamson,  Dr.,  treatment  of  ringworm,  300 

description  of,  301,  302 
Air-cooled  tubes,  34,  297 
Alimentary  canal,  foreign  bodies  in,  233 
Alimentary  system,  method  of  examination, 
209 

radiographic  appearances  of,  219 

radioscopy  of,  precautions  necessary,  218 

X-ray  examination  of,  209-234 
Alternating  current  supply,  3 

high-tension  rectifier,  5 

interrupters  for,  26 

smaller  outfits  made  for,  5 
Anaemia,   pernicious,   treatment  by  X-rays, 

324 
Anatomical  relations  of  urinary  tract,  239 
Aneurism,  aortic,  206,  207 

thoracic,  205 

(see  also  Chest) 
Ankle-joint,  epiphyses  of,  144 

fracture  dislocation  at,  P.  168-169 

fractures  at,  P.  168-169 

fractures  in  neighbourhood  of,  166 

in  child,  P.  147 

radiography  of,  136 

tubercular  disease  of,  P.  174,  P.  181 
Ankylosis,  175 
Anti-cathode,  39 

distance  from  plate  or  object  affects  in- 
tensity of  X-rays,  94 
Aorta,  examination  of,  205 
Apparatus  for  radiography,  arrangement  of, 
80-90 

a  convenient  form  of,  81 

for  heavy  discharges,  4 
principle  of,  4 

for  single  impulse  radiographs,  5 

portable,  81 
Appendix,  concretions  in  the,  241 
Arthritic  changes  in  joints,  P.  176 
Arthritis  following  injury  to  knee-joint,  176 

hypertrophic,  178 


Articular  gout,  chronic,  177 
rheumatism,  chronic,  177 
Asthma,  201 

Astragalus  (see  Ankle-joint) 
Atlas,  ossification  of,  143 
Atrophy  of  bone,  172,  177 
Axis,  ossification  of,  143 

Barkla,    work    on    secondary    radiations    of 

metals,  254 
Batten,  Dr.,  treatment  of  skin  disease,  299 
Battery  for  Coolidge  tube,  37 
Bauer  air-valve,  193 

regulator,  46,  52 
Bauer  qualimeter,  56,  57,  268,  278,  279,  281 

use  in  therapeutics,  57 
Beclard,    regarding    development    of   bones, 

138,  139 
Beclere,  emphasis  upon  continuance  of  X-ray 

treatment  in  blood  diseases,  326 
Becquerel  ray,  257 
Benign  cyst,  187 
Berry,  Dr.  Martin,  chair  for  radiography  of 

the  skull,  123,  125 
Bismuth  emulsion,  use  of,  209 

meal  (see  Opaque  meal) 
Bladder,  barium  injection  of,  P.  245 
calcuh  in,  243,  P.  244 

varieties  of,  244 
cancer  of,  treatment  by  radium,  377 
gallstones  in,  P.  244 
sacculi  of,  247 
Blood  changes,  effect  of  treatment  by  X-rays, 

253 
Blood,  diseases  of,  treatment  by  X-rays,  323 
duration  of,  324 
pernicious  anaemia,  324 
nature  of  action  of  X-rays  in,  326 
Blood  pressure,  effect  of  radium  emanations 

upon,  358 
Blood,  red  corpuscles  in,  effect  in  radiation 

treatment  of  malignant  disease,  254 
Blood-vessels,  effect  of  radium  upon,  257 
Bone,  cancer  of,  179 
carcinoma  of,  184 
chronic  inflammation  of,  170 
disease,  cystic,  Elmslie's  examples,  173 
diseases  of,  167-173 
inflammatory  affections  of,  168-173 


391 


392 


RADIOGRAPHY 


Bone,  morbid  conditions  of,  173 
sarcoma  of,  179 
simple  atrophy  of,  172 
syphilitic  diseases  of,  171,  180 
tuberculous  disease  of,  170 
tumours  of,  179,  180 

differential  diagnosis  of,  185-187 
Bones,  chronic  inflammatory  conditions  of, 
P.  170-171 
development  of,  138-143 
normal,  radiography  of,  123 
of  chest  (see  Chest) 
of  foot  (.see  Foot) 
tumours  of,  P.  183,  P.  186 
Bones  and  joints,  injuries  of,  154-166 

{see  also  Diseases  of) 
Bordier,  Dr.,  chromo-radiometer,  282,  321 
formula  for  filtration,  321 
technique  in  treatment   of  uterine  fibro- 
mata, 319 
of  uterine  fibroids,  321 
Bowel,  radium  tube  introduced  into,  376 
Brain,  bullet  in,  119 

Breast,  atrophic  scirrhus  cancer  treated  by 
radiations,  P.  316 
cancer    of,    post  -  operative    prophylactic 

treatment,  379 
carcinoma  of,  treatment  by  radium,  370, 

372 
carcinoma  treated  by  X-rays,  P.  372 
diseases  of,  radium  treatment  should  be 
confined  to  inoperable  cases,  372 
ulcerated  carcinoma  treated  by  X-rays, 
P.  314 
Breschet,  regarding  development   of  bones, 

143 
British    Medical    Association,    discussion    at 
Liverpool    meeting     of    Electro-Thera- 
peutic Section  with  Anatomical  Section, 
210 
Bronchiectasis,  203 
Bronchitis,  chronic,  201 
Broncho-pneumonia,  194 
Bruce,  Dr.  Ironside,  method  of  centering  the 

tube,  95 
Brunning    ajjparatus     for    examination     of 

oesophagus,  374 
Brush  high-frequency  discharges,  255 
Bullet  in  brain,  119 
Bumm,    Professor,    results    of    experiments 

with  radiations,  380 
Bythell,  Dr.,  report  on  diseases  of  lungs,  201 

Caecum,  description  of,  231 

Caecum    and    ilium,    opaque    meal    in,    230, 
231 

Calcareous  kidney,  P.  243 

Calcified  mesenteric  glands,  P.  243 

Calculi  in  the  bladder,  243 
varieties  of,  244 
in  the  kidney,  241 
in  the  ureter,  242,  243 
urmary,  241-244,  P.  241,  P.  244, 

Calculus  in  ureter,  P.  245 


Cancer    (atrophic    scirrhus),    treatment    by 
radiations,  P.  316 
of  the  bladder,  treatment  by  radium,  377 
of  bone,  179 
of  the  breast  should  receive  prophylactic 

treatment,  379 
of  the  cervix  uteri,  treatment  by  radium, 
366 
exposure  for,  367 
en  cuirasse,  treatment  by  radium,  372 
effect  of  hard  Beta  and  Gamma  rays  of 

radium  upon,  254 
increase  in  size  may  occur  as  a  result  of 

radium  treatment,  259 
in  lungs,  201 

mediastinal.  X-ray  treatment  of,  382 
in  mouth,  treatment  by  radium,  373 
in  oesophagus,  treatment  by  radium,  374 
of  prostate  gland,  treatment  by  radium, 

376 
of  the  rectum,  treatment  by  radium,  375 
recurrent,  treatment  by  radium,  372 
of  stomach,  227 

in  tongue,  treatment  by  radium,  373 
treatment  by  X-rays,  292 
Cancer    Hospital,    London,    Dr.    Jefferson's 
radiographs  of  stomach,  217 
results    obtained   in    examination    of   the 
thorax,  194 
Cancer  Hospital  Research  Laboratory,   Dr. 
R.     W.     A.     Salmond's     investigations 
regarding  filter  equivalents,  293 
Carcinoma  of  bone,  184 

of  the  breast,  treatment  by  radium,370,372 
mammae,  P.  171 

X-ray  treatment  of,  382 
recurrent  after  removal  of  breast,  treated 

by  radiations,  P.  372 
secondary,  187 

in  chest,  P.  199,  P.  201 
superficial,  treatment  of,  255 
of  the  tonsil,  treatment  by  radium,  370 
treatment  by  radiations,  P.  372 
treatment  by  radium,  371 
ulcerated,  treatment  by  X-rays,  P.  314 
of  the  uterus,  combined  use  of  radium  and 
X-rays,  382 
Carcinomata,  favourable  influence  of  X-rays 
upon,  328 
treatment  by  X-rays,  312 

methods,  before  operation,  313 

post-operative,  313 
results  of  prophylactic,  314 
treatment  of  inoperable,  by  X-rays,  315 
of  recurrent,  by  X-rays,  316 
of  ulcerated  growths,  315 
Carcinomatous  glands,  treatment  by  X-rays, 

308 
Caries,  168 

of  spine,  P.  179 
sicca,  P.  175 
Carpal  bones,  fractures  of,  164 

investigations  regarding  injuries  to,  164 
table  of  development  of  the,  149 


INDEX 


393 


Case,  Dr.,  radiographs  of  gallstones,  214 
Cell   growth,   influenee   of  radiations   upon, 

383 
Cervical  region,  radiography  of,  130,  131 
Cervical    vertebrae,     showing     position    for 

demonstration  of  cervical  ribs,  191 
Caries  of,  P.  179 
injuries  of,  156,  157 
ossification  of,  143 
Cervix,  chronic  inflammatory  conditions  of, 

treatment  by  radium,  365 
Cervix  uteri,  cancer  of,  treatment  by  radium, 

3GG 
Charcot's  joints,  178 
Cheloid,  treatment  by  radium,  363 

treatment  by  X-rays,  304 
Chest,  bones  of,  radiography  of,  131 

malignant    diseases   of,    P.    188,    P.    199, 

P.  201,  P.  204 
showing  aneurism,  P.  207 
calcareous  glands,  P.  204 
chronic  pleurisy,  P.  202 
dilatation  of  oBSophagus,  P.  211 
distended  stomach,  P.  204 
lobar  pneumonia,  P.  201 
pleural  effusions,  P.  190 
pulmonary  tuberculosis,  P.  194,  P.  197 
secondary  carcinoma,  P.  199,  P.  201 
walls,  tumours  of,  197,  204 
Chondromata,  185 

Cinematographic  demonstrations  of  contrac- 
tions of  stomach,  219 
Classification  of  inflammatory  affections  of 

bone,  168-173 
Clavicle,  development  of,  138 
fracture  of,  158 
radiography  of,  131,  132 
(see  also  Shoulder-joint) 
Climacteric  troubles,  Albers-Schonberg  tech- 
nique with  X-rays,  320 
Coil,  therapeutic,  269 
Collargol  solution,  technique  of  examination 

with,  247 
Colles  fracture,  162,  P.  163 
Colon,  bismuth  food  in,  232 
description  of,  232 
kinks  in,  231 
opaque  enema  in,  P.  234 
opaque  meal  in,  P.  222 
{see  also  Stomach) 
Compression,  method  of,  69,  132 
Compressors,  67-69 

Albers-Schonberg,  67,  68 

description  of,  69 
kidney,  69 

Dr.  Gilbert  Scott's,  69 
screening  stand  used  as,  72 
Condenser,  construction  of,  15 
Congenital  malformations,  248,  P.  248 

sjrphilis,  171 
Congestion  of  the  lungs,  194 
Connections  of  X-ray  tube  to  coil,  40 
Constipation,  chronic,  233 
intestinal,  233 


Constitutional  disturbance  due  to  radiations, 

262 
Continuous  current  supply,  3 
Control  apparatus,  15 

table,  23,  24 
Converter,  motor,  9 
Coolidge  tube,  3o-38,  94,  95,  269,  294 
battery  for,  37 
for  heavy  currents,  296,  297 
method  of  operating,  38 
Cooper,  Astley,    and    fracture    of    neck    of 

scapula,  158 
Coronoid,  fracture  of,  161 
Cossar  tube,  296 
Couch,    X-ray,   for    therapeutic    treatment, 

276 
Couches,  67-72 

a  convenient  form  of,  67 
fitted  with  protected  tube-box  underneath, 
68 
Cranial  radiography,  chair  for,  127,  128 
Craniotabes,  172 
Curie,     Professor     and     Madame,     unit     of 

measurement  for  radium,  342 
Current,  reverse  (inverse),  161,  279 
method  of  detecting,  53 
produces  secondary  rays,  54 
suppression  of,  48,  52 
supply,  alternating,  3 

alternating,  interrupters  for,  26 
continuous,  3 
400- volt  circuits,  6 
high-tension  is  alternating,  9 
Cyclops  tube,  297 
Cylinder  diaphragm,  use  of,  55 
Cyst,  benign,  187 

dermoid,  in  pelvis,  P.  246 
hyatid,  184,  187,  204 
in  the  heart,  205 
Cystic  conditions  of  the  kidney,  246 
disease  of  bone,  Elmslie's  examples,  173 

Dactylitis,  syphilitic,  180 

tubercular,  180 
Dark  room,  82,  84 

Dawson's  formula  for  localisation,  113 
Deformities,  congenital,  P.  248 
Degrais  on  changes  which  occur  in  radium 

therapy,  257,  258 
Dermatitis,  acute,  263 

chronic,  263 
Dermoid  cyst  in  pelvis,  P.  246 
Dessaeur  tube,  34,  296 
Developer,  choice  of,  97 

preparation  of,  98 
Development  of  bones,  138-143 

of  X-ray  plates,  238 
Diagnosis,  97 

consideration  of  all  the  factors  essential 
for,  193 

value  of  combined  clinical  and  radiographic, 
185 
Diaphragm,  use  of,  55 

cylinder,  use  of,  55 


394 


EADIOGKAPHY 


Diaphragm,  irregularities  in  the  outline  of, 

204 
Di -electric,  21 

Disease,  general,  radium  applied  to,  357 
effect  of  radium  applications  in,  358 
practical  application  of  radium  to,  345-377 
Diseases  of  bone,  167-173 

of    bones    and    joints,    differential    X-ray 

diagnosis  in,  179-187 
of  joints,  174-178 
Dominici,   early  work  with  Gamma  ray  of 

radium,  251 
Dorsal  vertebrae,  191 

curvature  of,  P.  179 
injuries  of,  157 
radiography  of,  132 
Dosage,    Bordier's   chromo-radiometer,    282, 
321 
epilation  dose,  290 
Hampson's  radiometer,  290,  291 
Holzknecht's  quantimeter,  282 
incident  dose  for  uterine  fibroids,  322 
lonto  quantimeter,  287 
Kienbock  quantimeter,  282 
arrangement  for  exposure,  283 
development  of  strips,  283,  284 
the  standard  scale,  285 
tints  of  developed  strips,  286 
Lovibond's  tintometer,  288,  290 
methods  for  estimating,  279-292 
record  of  exposures,  287 
Sabouraud  and  Noire  pastilles,  279 
units    of    measurement,     comparison    of, 
321 
Dosage  in  radium  therapy,  353 
of  emanation  in  solution,  355 
Mache  unit,  355 
relation  between  the  value  of  radium  and 

its  activity,  354 
salts,  age  of,  354 
salts,  variation  of  activity,  355 
standard  of  activity,  353 
unit  of  milligram-hours,  356 
unit  of  radiation,  353 
when  the  free  radium  is  contained  in  metal 

tubes,  356 
when  using  flat  applicators,  355 
when  using  the  Gamma  ray  alone,  356 
Duodenum  (see  Intestine,  small) 
Dust  and  smoke,  effect  of  inhalation  of,  201 
Dynamo  for  military  hospital,  87 
Dynamos,  11 
Dyschezia  (see  Intestine,  large) 

Ear,  diseases  of,  treatment  by  radium,  359 
Eczema,  chronic,  treatment  by  radium   361 

362 
Eczemata,  treatment  by  X-rays,  299 
Edinburgh  Royal  Infirmary,  case  of  fracture 

of  neck  of  scapula,  159 
Edouel,  explanation  of  action  of  X-rays  in 

blood  diseases,  326 
Ehrhch,      condition     termed     myelogenous 

leukaemia,  325 


Elbow-joint,  dislocation  of,  161 
epiphyses  of,  150,  151 
fracture  dislocation  of,  P.  161 
fracture  through  head  of  radius,  P.  161 
fracture  through  lower  end  of  humerus, 

P.  161 
fracture  through  olecranon  process,  P.  138 
injuries  in  the  region  of,  161 
injury  to  epiphysis  of  olecranon,  P.  138 
normal,  P.  138 
radiography  of,  134 
Electric  energy,  sources  of,  3 

motive  force  or  spark  length,  14 
Electrical  supply  for  military  hospital,  87 
Electroscope,  267 

special  gold  leaf,  for  radium,  332 
friction  device  for  charging,  342 
Elmslie,  examples  of  cystic  disease  of  bone, 

173 
Emery,  Dr.,  report  on  tumour  of  tibia,  183 
Empyema,  204 
Endometritis,  chronic,  treatment  by  radium, 

365 
Endotheliomata,  treatment  by  X-rays,  328 
Epiphyses  of  hip-,  knee-,  and  ankle-joint,  P. 
147 
of  joints,  radiographic  survey  of,  144-153 
of  lower  end  of  radius,  displaced,  P.  164 
separation  of,  161 
Epiphysitis,  syphilitic,  171 

tuberculous,  170 
Epithelioma,  distinction  from  rodent  ulcer, 
311 
infiltrating,  treatment  by  radium,  370 
superficial,  methods  of  treatment,  368 
treatment  by  radium,  368,  369 

early  cases  are  readily  influenced,  368 
Epitheliomata,  treatment  by  X-rays,  312 
Erythema  dose,  57,  58 
Ethmoidal  sinuses,  radiography  of,  128 
Examining  chair,  universal,  78,  79 
Exophthalmic  goitre,  treatment  by  radium, 
360 
treatment  by  X-rays,  317 
object  of  treatment,  318 
Exostoses,  185 

Exostosis  of  angle  of  scapula,  P.  156 
Exposure,  duration  of,  42 

table  for  radiographs,  93 
Eye,  diseases  of,  treatment  by  radium,  359 
and  orbit,  localisation  of  foreign  bodies  in, 
115-118 
Sweet's  localiser,  118 
simple     methods     for     localising     foreign 
bodies  in,  119 
Eyeball,    method   of  localisation   of   foreign 

bodies  in,  115 
Eyelid,  epithelioma  in,  treatment  by  radium, 
370 

Face,   rodent  ulcers   treated  by  radiations, 

P.  309,  P.  311,  P.  368 
Femur,  development  of,  141 
epiphyses  of,  145,  148 


INDEX 


395 


Temur,  exostoses  of,  185 
fractures  of,  165 
radiography  of  shaft  of,  135 
sarcoma  of,  182,  F.  183,  P.  186 
(see  also  Hip-joint  and  Knee-joint) 
Fibroma  uteri,  treatment  by  X-rays — 
indications  for,  319 
contra-indications,  319 
Fibromata,  treatment  by  radium,  367 
Fibula,  development  of,  142 
epiphyses  of,  145 
fractures  of,  147,  165 
radiography  of,  136 
(.966  also  Leg  and  Ankle-joint) 
Filters,  additional,  293 
selection  of,  293 
use  of,  292 
Filtration,  Bordier's  formula,  321 
Finsen  light  in  treatment  of  lupus,  304 
Finzi,  Dr.,  method  of  radiography,  127 
Fissures,  treatment  by  X-rays,  305,  306 
Fluoroscopy  for  determination  of  injuries  to 

joints,  154 
Folliculitis  barbae,  treatment  by  X-rays,  303 
Foot,  bones  of — 

congenital  deformity  of,  P.  248 
development  of,  142 
fractures  of,  P.  169 
radiography  of,  136,  145 
Forearm,    fracture    through    lower    end    of 
radius,  P.  162 
fracture  of  trapezium,  P.  162 
non-union    fracture    of   ulna    and    radius, 
P.  162 
Foreign  bodies  in  the  alimentary  canal,  233 
in  the  oesophagus,  210 
in  the  pleural  cavity,  204 
in  the  thorax,  197 
localisation  of,  107 
Fracture,  morbid  conditions  of  bone  which 

predispose  to,  173 
Freiburg  School,  technique  in  carcinoma  of 
the  uterus,  382 
technique  in  treatment  of  uterine  fibro- 
mata, 319,  322 
French  valve  tube,  51 

Fulham  Cancer  Hospital,  Electrical  Depart- 
ment, 86 
Fuses,  main,  should  always  be  accessible,  3 

Gaiffe  mercury  interrupter,  3,  26 
GaifEe  Rochefort  outfit,  4 

transformer,  3 
GaUstones,  P.  244 

reference  to  Dr.  Case's  radiographs  of,  214 
Gas  engine,  11 

Gauss,   Dr.,   technique  for  treating  uterine 
fibroids  by  X-rays,  322 
therapeutic  tube-stand,  276 
Glands,  enlarged,  treatment  by  X-rays,  307 
carcinomatous,   treatment    by  X- 

rays,  308 
mediastinal,  treatment  by  X-rays, 
327 


Glands,  enlarged  sarcomatous,  treatment  by 
X-rays,  308 
inflammatory,  treatment  by  X-rays,  307 
lymphadenomatous,  treatment  by  X-rays, 

307 
prostate,  cancer  in,  treatment  by  radium, 

37G 
thyroid,  treatment  by  radium,  360 
tuberculous,  treatment  by  radium,  307 
Glossary,  387-390 
Gout,  chronic  articular,  177 

rheumatic,  178 
Granulation  tissue,  treatment  by  radium,  359 
Great   Northern    Central    Hospital,    case    of 

fracture  of  neck  of  scapula,  159 
Groedal,  Dr.  Franz,  of  Mannheim,  207 
examples    of    cardiac    conditions    of    the 

heart,  207 
preparation  of  and  results  obtained  with 
opaque  meal,  215 
Gundelach  regulator,  47 
tube,  35,  296 
valve  tube,  52 
Guy's  Hospital  Museum,  example  of  fracture 
of  neck  of  scapula,  158 

Haenisch,  Dr.,  method  of  using  opaque  meal 
for  examination  of  large  intestine,  218 
technique  in  treatment  of  uterine  fibroids, 
319 
uterine  fibromata,  319 
Hair,  efl'ect  of  radium  upon,  256 
Hampson,  Dr.,  localiser,  113,  114 

treatment  of  eczemata,  299 
Hand,  congenital  deformities  of,  P.  248 
development  of  bones  of,  140,  150 
fracture  of  terminal  phalange  of  thumb, 

P.  164 
fracture  through  base  of  metacarpal  bone 

of  thumb,  P.  164 
fractures  of  bones  of,  164 
oblique   fracture   of   shaft   of   metacarpal 

bone  of  little  finger,  P.  164 
normal  adult,  P.  164 
radiograph  of  normal,  96 
tubercular  disease  of,  P.  175 
Haudek,  Dr.,  double  opaque  meal,  218 
radiographic  diagnosis  of  hour-glass  con- 
traction, 223 
Heart,  aortic  aneurism.  206,  207 
cyst  in,  205 
diseases  of,  195 
enlarged,  P.  201 
examination  of,  205 
examination  of  patient  in  three  positions, 

206 
examples  of  cardiac  conditions  by  Groedal, 

207 
exposure  for,  5 
showing  atheroma,  P.  246 
Stokes-Adams  disease,  205 
syphilis,  195 
thoracic  aneurism,  205 
tuberculosis  of,  195 


396 


RADIOGRAPHY 


Heart,  tumours  of,  195,  196 

variation  in  size,  shape,  and  position  of,  205 
Heavy  discharges,  apparatus  for,  4 
Hertz,  Dr.,  description  of  three  positions  of 
stomach,  211-214 
opinion  regarding  kink  at  duodenum,  233 
preparation  of  and  results  obtained  with 
opaque  meal,  215 
High-tension  current  is  alternating,  9 
for  rapid  radiographs,  10 
rectifier  for  valve  tubes,  4,  9,  51 
Hip-joint,  dislocation  of,  P.  166 

displacement  of  upper  end  of  femur  in  a 

child,  P.  167 
epiphyses  of,  147,  148 
fracture  of  femur,  P.  166,  (2)  P.  169 
fragment  of  shell  in,  120 
in  child,  P.  147 
injuries  near,  164 
normal,  P.  166 
radiography  of,  135 
tuberculosis  of,  175 
tuberculous,  P.  173 
Hodgkin's  disease,  196,  199 
treatment  by  X-rays,  324 
HoUand,  Dr.  Thurstan,  case  of  stone  in  the 

ureter,  243 
Holzknecht,    bismuth    examination    of    the 
stomach,  219 
chromo-radiometer,  compared  with   Kien- 

bock  method,  285 
diagrams  to  illustrate  aneurism,  etc.,  207 
grouping     of     radiographic     and     clinical 
results    of    bismuth    examination    of 
stomach,  219 
quantimeter,  281 

report  on  aneurism  of  the  aorta,  208 
Hospital,  base,  installation  for  {see  Military 
hospital) 
Cancer,  electrical  department,  86 
general,  electrical  department,  84 
organisation  of,  85 
installation  for,  82,  83 
special,  installation  for,  85 
Hour-glass  contraction  (see  Stomach) 
Humerus,  development  of,  139 
fractures  of,  159,  160,  161 
sarcoma  of,  P.  183,  P.  186 
(see  also  Shoulder-joint  and  Elbow-joint) 
Hydatid  cyst,  184,  187,  204 
Hyoid  bone,  development  of,  142 
Hyperidrosis,  treatment  by  X-rays,  305 
technique  in  axillae,  305 

Ileum  {see  Intestine,  small) 

Ileum  and  caecum,  opaque  meal  in,  230,  231 

Induction  coils,  7,  12,  13 

essential  parts  of,  12 
Inflammation  of  bone,  chronic,  169 
Inflammatory  affections  of  bone,  classifica- 
tion of,  168-173 
glands,  treatment  by  X-rays,  307 
Injuries  of  bones  and  joints,  154-166 
Installations  (see  X-ray  installations) 


Intensifying  screen,  use  and  value  of,  06 
International     Congress,     1913,     Radiology 

Section,  222 
Interrupters,  causes  of  defective  working,  21 
di-electric  used,  21 
dipping,  271 
electrolytic,  271 
advantages  of,  24 
description  of,  22 
disadvantages  of,  25 
method  of  action,  25 
single-point,  23 
three-point,  23 
for  alternating  current,  26 
for  military  hospital,  87 
Gaiffe  mercury,  3,  26 
improved  Mackenzie  Davidson,  22 
Instanta,  20 
mercury,  270 

description  of,  17 
Rythmeur,  274 
Sanax,  20,  81 

Watson  Dreadnought,  IS,  19 
Wehnelt,  6,  22 
advantages  of,  24 
Interruptions,  number  of,  21 
Intestinal  stasis,  233 

method  of  examination  for,  229 
Intestines,  fsecal  matter  in  the,  241 
foreign  bodies  in  the,  241 
large.  Dr.  Haenisch's  method  for  examina- 
tion of,  218 
Dr.    Haudek's   double-meal   method   of 

examination,  218 
dyschezia,  233 
examination  of,  231 
tumours  of,  233 
small,  duodenal  ulcer,  230 
examination  of,  229 
the  duodenum,  229 
the  jejunum  and  ileum,  230 
Inverse  (reverse)  current  (see  Current) 

Jaw,  dentigerous  cyst  in  lower,  P.  129 
fracture  of  angle  of,  155 
of  lower,  120 

through  ramus  of  lower,  P.  129,  155 
radiography  of,  129 
Jefferson,  Dr.,  radiographs  of  stomach  ob- 
tained at  Cancer  Hospital,  216 
Jejunum  (see  Intestine,  small) 
Johnson,     Herneman,    work    on    secondary 

radiations  of  metals,  254 
Joints,  appearance  of  tuberculosis  in,  179 
diseases  of,  174-178 
loose  bodies  in,  177 
normal,  radiography  of,  123 
tuberculous  disease  of,  174 
Joints  and  bones,  injuries  of,  154-166 
Joints  and  epiphyses,  radiographic  survey  of, 

144-153 
Jordan,  Dr.,  demonstration  of  ileal  stasis,  233 
of  kinks  in  colon,  231 
report  on  diseases  of  lungs,  201 


INDEX 


397 


Kidney,  calcareous,  P.  243 

calculi  in,  P.  241,  241,  245 

collargol  in,  P.  245 

cystic  conditions  of,  246 

description  of,  239 

disease,  in  doubtful  cases  try  other  methods 
of  examination,  246 

enlarged  movable,  244 

fsecal  mass  in,  P.  241 

relations  of,  240 

tuberculous  disease  of,  244 

tumours  of,  245 
malignant,  245-246 
simple,  245 
Kienbock  quantimeter,  282 

arrangement  for  exposure,  283 

development  of  strips,  283,  284 

slips,  use  when  treating  uterine  fibroids,  323 

standard  scale,  285 

tints  of  developed  strips,  286 

treatment  of  ringworm,  300 
King's   College    Hospital,    electrical   depart- 
'ment,  82,  84 

filter  and  screen  for  radium  in  use  at,  340 
Knee-joint,  arthritic  changes  in,  P.  176 

chronic  inflammatory  conditions  of  bones, 
P.  170 

epiphyses  of,  145,  146,  147,  148 

fracture  of  patella,  P.  168 
of  lower  end  of  femur,  P.  168 

in  child,  P.  147 

injuries  to,  P.  168 

normal,  P.  140 

radiography  of,  135 

rheumatoid  changes  in,  P.  176 

showing  chronic  inflammatory  conditions 
of  epiphyses,  P.  168 

tubercular  disease  of,  P.  174,  P.  181 

tuberculosis  of,  176 
Krauss,  explanation  of  action  of   X-rays  in 
blood  diseases,  326 

Lane,  Sir  Arbuthnot,  description  of  kinks  in 

ileum,  231 
Leg,  fractures  of  bones  of,  P.  168-169 

inflammatory  and  other  affections  of  bones 
of,  P.  171 
Lembcke,    technique    for    treating    uterine 

fibroids  by  X-rays,  322 
Leonard,     Dr.     Lester,     demonstration     of 
changes    in    length     and     breadth     of 
stomach,  221 
report  to  radiology  section  of  the  Inter- 
nationa.1  Congress,  222 
Leucoplakia,  treatment  by  X-rays,  299 

treatment  by  radium,  364 
Leucoplakia  vulvse,  treatment  by  radium,  366 
Leukaemia,  treatment  by  X-rays,  253,  324, 

325 
Lichen,  treatment  by  X-rays,  299 
Localisation  of  foreign  bodies,  107-122 
in  the  eye  and  orbit,  115-118 
in  hip  and  shoulder,  120,  121 
in  limbs,  121 


Localisation  of  foreign  bodies  in  the  skull, 
110-128 
Dawson  Turner  formulae,  113 
Hampson's  method,  113,  11-1,  121 
Mackenzie  Davidson  short  method  of,  113, 
113,  119,  121,  122 
for  foreign  bodies  in  eyeball,  115 
Mackenzie  Davidson  method  in  combina- 
tion with  stereoscop3%  119,  121 
Shenton's  method,  115,  121 
simple  methods  of,  109,  110 
stereoscopic  method,  118 
Localiser,  Mackenzie  Davidson,  107 
cross-thread.  111 
Sweet,  118,  123,  124 

for  radiographs  of  the  skull,  123 
Wheatstone,  108 
Lovibond's  tintometer,  288 
Lumbar  vertebrae,  curvature  of,  P.  179 
ossification  of,  143 
radiography  of,  132 
Lungs,  abscess  of,  203,  204 
actinomycosis  of,  202 
Bythell's  report  of  examinations  of,  201 
cavities  in,  202 

circulatory  disturbances  in,  194 
cirrhosis  of,  194 
congestion  of,  194 
diseases  of,  194 

differential  diagnosis,  198-204 
treatment  by  X-rays,  327,  328 
exposure  for,  5 
Hodgkin's  disease,  196,  199 
infarction  of  the  lung,  200 
Jordan's  report  of  examinations  of,  201 
lympho-sarcomata,  199 
primary  malignant  growths  of,  199 
pulmonary  apoplexy,  200 
sarcoma  in,  P.  188,  199 
tuberculosis  of,  195 
tumours  of,  196,  198 
Wasserman  reaction  in  diseases  of  lungs, 

202 
(see  also  Chest) 
Lupus  erythematosus,  treatment  by  X-rays,, 
304 
treatment  by  radium,  363 
Lupus  vulgaris,  treatment  bv  Finsen  Hght,, 
304 
treatment  by  radium,  363 
treatment  by  X-rays,  304 
Lymphadenoma,  treatment  by  X-rays,  328 
Lymphadenomatous    glands,    treatment    by 

X-rays,  307 
Lymphatic  leukemia,  treatment  of,  by  X- 
rays,  325 


Macalaster  Wiggin  tube,  295,  296 

Mache,  Professor,  unit  of  measurement  for 

radium,  343,  355,  356 
Mackenzie  Davidson  localiser,  107 

cross  thread  localiser.  111,  112 
method,  110,  111,  119-122 


398 


KADIOGKAPHY 


Mackenzie  Davidson  method  of  localisation 
for  foreign  bodies  in  eyeball,  115 
in  combination   with   stereoscopy,    119, 
121 
short  method  of  localisation,  113 
Mackenzie  Davidson's  experience  of  radium 

treatment  in  diseases  of  the  eye,  359 
Malformations,  congenital,  248 
Malignant  disease,  combined  use  of  radium 
and  X-rays  in  treatment  of,  378 
in  treatment  endeavour  to  keep  up  per- 
centage of  red  corpuscles  in  the  blood, 
254 
treatment  by  radium  is  purely  local,  263 
treatment  of,  radium  and  X-rays  are  im- 
portant therapeutic  factors,  383 
Malignant  invasions   of  skin,   treatment   by 

X-rays,  305 
Malleoli  (see  Ankle-joint) 
Mammae,  carcinoma  of,  X-ray  treatment  of, 

382 
Manipulation  of  X-ray  tube,  43 
Marie  and  Ribaut's  exposure  table,  105 
Mastoid  sinuses,  position  for  radiography  of, 

126 
Maxilla,  inferior,  fractures  of,  156 

superior,  fractures  of,  156 
Mediastinal  cancer.  X-ray  treatment  of,  382 
glands,  enlargedjtreatment  by  X-rays,  327 
Mediastinum,  diseases  of,  196 

treatment  by  X-rays,  327,  328 
tumours  of,  197 
Medullary  sarcoma,  187 
Melchener  and  Wolff,  experiments  regarding 

action  of  X-rays  upon  blood,  326 
Meningocele  in  infant,  P.  248 
Mercury  vapour  lamp,  255 

treatment  for  rodent  ulcers,  311 
Mesenteric  glands,  calcified,  P.  243 

enlarged  and  calcified,  241 
Mesothorium  and  radium,  381 
Metacarpal  bones,  development  of,  140 
fractures  of,  164 
radiography  of,  134 
Metatarsal  bones,  development  of,  142 
radiography  of,  136 
{see  also  Foot) 
Mica  regulator,  44,  45 

Military  hospital  (base),  installation  for,  87 
collecting  hospital,  87 

electrical  supply,  87 
petrol  engine  and  dynamo,  87 
portable  accumulator  batteries,  87 
X-ray  installation,  8S,  89 
field  outfit,  90 

necessary  apparatus,  90 
radiography,  equipment  for,  87 
Miller,  Dr.  Leslie,  mica  disc  valve,  272 
Milliamperemeter,  for  measuring  X-rays,  57, 
60 
D'Arsonval  moving-coil  dead-beat  precision 
type,  267,  279 
Milligram-hours,  unit  of  radium  dosage,  356 
MoUites  ossium,   173 


Morton  rectifier,  272 

Motor  transformers,  12 

Mouth,  cancer  in,  treatment  by  radium,  373 

examination  of,  by  radiography,  129 
Miiller,  condition  termed  myelsemia,  325 
Miiller  water-cooled  tube,  321 
Muscle  fibres,  effect  of  radium  upon,  257 
Myela;mia,  325 
Myelogenous  leuksemia,  325 
Myeloma,  187 

Nsevus,  treatment  by  radium,  362 

a  good  routine,  362 
Xasal  bones,  fractures  of,  156 
Necrosis,  167 

Nerve  tissue,  effect  of  radium  upon,  256 
Neuritis,  264 
Normal  tissues,  changes  in,  due  to  radiations, 

P.  254 
Nose,  diseases  of,  treatment  by  radium,  359 

(Esophageal  tube,  radium  tube  arranged  in, 

374,  375 
Oesophagus,  bismuth  food  in,  211 

bismuth  food  in  stricture,  P.  129 

Brunning   apparatus  for  examination   of, 
374 

cancer  of,  treatment  by  radium,  374 

examination  of,  209,  210 

foreign  bodies  in,  210 

tumours  of,  197 

(■see  also  Chest) 
Olecranon,  fracture  of,  161 
Oliver  Lodge  valve  tube,  51 
Opaque  meal,  214,  217 

Dr.  Haenisch's  method  for  examination  of 
large  intestine,  218 

Dr.  Haudek's  double-meal  method,  218 

in  colon,  232 

in  ileum  and  csecum,  230,  231 

precautions  to  be  observed  in  the  conduct 
of,  218 

radiographic  appearances  of,  219 

reasons  for  using  barium  sulphate,  216 

variations  of,  for  special  investigations,  218 
Orbital  region,  fractures  in,  156 
Orthodiagraph,  77 
Orthodiagraphy,  206 
Os  calcis,  fracture  of,  166 
Oscilloscope  tube,  action  of,  53 

for  detecting  reverse  current,  53,  278 
Os  innomrnatum,  development  of,  140 
Osmosis  regulator,  193,  273 
Osteitis,  P.  170-171 

fibrous,  187 

of  cancellous  tissue,  168 

of  compact  bone,  168,  170 

tuberculous,  170 

typhoid,  169,  170 
Osteoarthritis,  178 
Osteomalacia,  173 
Osteomyelitis,  168,  P.  170-171 

acute,  181 

description  of  typical  X-ray  picture,  181 


INDEX 


399 


Osteomyelitis,  acute  infective,  109 
septic,  109 
chronic  infective,  180 

Panton   and   Tidy,   results   of  treatment   of 

blood  diseases  by  X-rays,  320 
Papillomata,  treatment  by  radium,  359 

superficial,  treatment  by  radium,  363 
Parrot's  nodes,  171 
Patella,  development  of,  141 

fractures  of,  165 

radiography  of,  135 

(see  also  Knee-joint) 
Pelvis,  dermoid  cyst  in,  F.  246 

development  of,  148 

displacement  of  upper  end  of  femur,   /-'. 
166-167 

examination  of,  by  radiography,  133,  135 

fracture  of,  in  child,  P.  167 

fractures  of,  164 

in  child,  P.  147 

normal  female,  P.  133 

normal  male,  P.  133 
Penetrans  tube,  295 
Periosteal  proliferation,  180 
Periostitis,  168,  170,  P.  170,  180 

acute  infective,  182 

acute  localised,  169 

tuberculous,  170 
Petrol  engine  for  military  hospital,  87 
Phalanges,  development  of,  140,  142 

fractures  of,  164 

radiography  of,  134,  136 
Phleboliths,  241 
Phthisis,  fibroid,  195 
Pirie,  Dr.  Howard,  hand  stereoscope,  106, 108 

technique,  125 

treatment  of  hyperidrosis  by  X-rays,  305 
Pleura,  differential  diagnosis  in  diseases  of, 
203 

diseases  of,  195 

purulent  effusion,  204 

secondary  cancerous  deposits  in,  204 

tumours  of,  196 
Pleural  cavity,  foreign  bodies  in,  204 

effusion,  serous,  203 

effusions  in  chest,  P.  190 
Pleurisy,  chronic,  203 

(see  also  Chest) 
Pneumokoniosis,  203 
Pneumonia,  broncho-,  194 

chronic  interstitial,  195,  203 

lobar,  195,  202,  P.  201 

(see  also  Chest) 
Portable  accumulator  batteries,  87 
Pott's  fracture,  166 
Primary  beams  (X-rays),  54,  55 
Prophylactic  treatment,  should  be  given  in 
all  cases  of  cancer  of  the  breast,  379 

in  carcinomata,  results  encouraging,  314 
Prostate    gland,    cancer    in,    treatment    by 
radium,  376 

enlargement  of,  treatment  by  X-rays,  316 
technique,  317 


Protection  from  shocks,  65 

of  operator,  lead-lined  screen  for,  79 

of  patients  in  X-ray  department,  266 

of  workers  in  X-ray  department,  265,  266 

Prurigo,  treatment  by  X-rays,  299 
by  radium,  364 

Psoriasis,  treatment  by  X-rays,  299 
by  radium,  361 

Ptosis,  222,  223 

Pyloric  stenosis  (see  Stomach) 

Pyloroptosis,  223 

Pyo-pneumo  thorax,  204 

Qualimeter,  Bauer,  56,  57 

description  of,  268 

use  in  therapeutics,  57,  278,  279,  281 
Quantimeter,  Holzknecht's,  281 

lonto,  287 

Kienbock,  282,  283 

Radiation  therapeutics,  249-377 
treatment  by  radium,  329-377 
by  radium  and  X-ravs,  378-385 
by  X-rays,  251-328 
watch  carefully  the  action  of  both  treat- 
ments, 255 
Radiations  lead  to  constitutional  disturbance, 
(reaction)  262 
effect  upon  carcinoma,  P.  316,  P.  372 
normal  tissues,  P.  254,  256 
rodent  ulcer,  P.  309,  P.  311,  P.  368 
tissues,  251,  252 

description  of  plates,  259-261 
tumours,  P.  256,  P.  258,  P.  260 
ulcerated  carcinoma,  P.  314 
Radio-active  waters,  260 
Radiogene,  357 

Radiographic  plates,  development,    97,    102, 
103,  238 
exposure  of,  102,  103 
fixing,  99 

intensification,  100 
printing,  101 
reduction  of,  100 
washing  and  drying,  99 
Radiographic  prints,  101 

glazing  gelatino-chloride,  104 
Radiographic  room  at  special  hospital,  85 
Radiographic     survey     of     joints     showing 

epiphyses,  144-153 
Radiographs,     caution     regarding     distance 
between  subject  and  X-ray  tube,  95 
exposure  times,  95 
cinematographic,  105 
distance  from  subject,  92 
distant,  advantages  of,  75,  76 
exposure,  91 
exposure   table,    comparison    of   different 

radiometers,  93,  94 
in  reclining  position,  74 
intensifying  screen,  use  and  value  of,  96 
intensity  of  X-rays,  92 
management  of  tube  for  good,  238 
obtainable  of  all  parts  of  human  body,  69 


400 


EADIOGKAPHY 


Radiographs  of  the  heart,  5,  77 
of  all  kinds,  75 
of  the  lungs,  5 
of  normal  hands,  96 
of  internal  organs,  75 
of  the  stomach,  5,  75 
placing  of  photographic  plate,  95 
plate  or  film  employed,  91 
production  of,  91 
quality  of  tube,  92 
rapid,  6,  10,  93 

for  examination  of  urinary  tract,  236 
value  of,  193 
single  impulse,  8 
principle  of,  8 
"  standard  exposures,"  76 
standard  points  on  the  median  lines,  77 
stereoscopic,  105 
straightness  of  trunk  essential,  73 

apparatus  to  ensure,  74 
thickness  of  the  subject,  92 
use  of  intensifying  screen,  96 
with  single -impulse  outfit,  94 
Radiography,  cranial,  chair  for,  127,  128 
for  determination  of  injuries  to  joints,  154 
military,  equipment  for,  87 
of  the  alimentary  system,  209 
of  bones  and  joints,  normal,  123 
of  ethmoidal  sinuses,  128 
of  frontal  air  passages,  127 
of  the  skull  and  accessory  sinuses,  123,  125 
of  the  sella  turcica,  127 
of  the  sphenoidal  sinuses,  128 
of  thorax,  191-194 
of  turbinate  bones,  128 
stereoscopic,  105,  106 
Radiologist,  consulting,  installation  for,  82, 

83 
Radiometer,  comparison  of  exposures,  94 
Walter's,  58,  59,  61 
Walter-Benoist,  59,  61 
Wehnelt's  crypto-,  59,  61 
Radioscopy  of  the  alimentary  system,  209 
of  the  opaque  meal,  precautions  necessary, 

218 
of  thorax,  188 

routine  examination,  189 
technique  of  examination,  188-191 
the  recumbent  position,  188 
Radium,  an  important  therapeutic  agent,  383 
and  its  activity,  relation  between  the  value 

of,  354 
applicator  attached  to   a  uterine   sound, 

365,  366 
applicator  for  floor  of  mouth,  373 
apphcators,  various  forms  of,  340,  348,  350, 

351 
Beta  and    Gamma    rays    in    therapeutics, 

356 
cautions  regarding  use  of  large  quantities, 

353 
effect  upon  cancer,  P.  372 

rodent  ulcer,  P.  309,  P.  311,  Pit368 
filtration  of  rays,  350 


Radium,  influence  of  air-space,  352 
flat  applicators  for,  361 
Gamma  ray  alone,  356 
method  of  using,  345 

as  an  inhalation,  346,  347 

in  glass  or  metal  applicators,  347,  348, 

350,  351 
in  water,  346 
upon  metal  points,  347 
practical  application   of,  to   disease,  345- 

377 
salts  of,  348 
age  of,  354 
in  tubes,  349 
upon     linen     to     form     toiles     (French 

method),  349 
variation  of  activity,  355 
secondary  radiations  from  tubes,  351 
Radium,  physics  of,  329-344 

apparatus  for  charging  glass  applicators, 

334 
for  obtaining  radium  emanation,  333 
for  preparation  of  water  impregnated  with 

radium,  338 
curve  showing  decay  of  radium  emanation, 

335 
electroscope,  special  gold  leaf,  332 
friction  device  for  charging  electroscope, 

342 
ionisation  and  recombination,  331 
measurement,  341 
physiological  action,  343 
radium  emanation,  333 
units  of  measurement,  342 
values  for  the  weight  of  radium  element  in 

salts,  339 
various  forms  of  applicators,  340 
Radium  therapy,  329-377 

action  of  radiations  on  blood-vessels,  257 
on  hair,  256 
on  muscle  flbres,  257 
on  nerve  tissues,  256 
upon  normal  tissues,  256,  261 
upon  the  skin,  256 
on  sweat  glands,  257 
on  vascular  connective  tissue,  257 
application  to  the  interior  of  oesophagus, 
350,  351 
into  the  substance  of  tumours,  350,  352: 
applicators,  various  forms  of,  340,  348,  350,. 

351 
Becquerel  ray,  special  action  of,  258 
changes  induced  in  tumour  cells  by,  382 
dangers  attendant  on  the  use  of,  263 

late  manifestations,  264 
dosage  in,  353 

of  emanation  in  solution,  355 

unit  in  milligram-hours,  356 

when  the  free  radium  is  contained  in 

metal  tubes,  356 
when  using  flat  applicators,  355 
when  using  the  Gamma  ray  alone,  356 
early  work  of  Dominici  with  Gamma  ray,, 
251 


INDEX 


401 


Radium  therapy,  early  work  of  Wickjiam, 
251 
effect  of  Beta  rays,  251,  258 

of  radiations  upon  blood-pressure,  358 
upon  tumour  cells,  258 
exercises  an  action  upon  all  living  cells,  259 
external  and  internal  application,  350 
factors  influencing  the  result  of  treatment, 

260 
filtration  of  rays,  350 
Gamma  ray,  action  upon  cancer,  265 
hard  Beta  rays  and  Gamma  rays,  effect 

upon  cancer,  254,  259 
heavy  doses,  important  points  regarding, 

381 
in  diseases  of  the  ear,  359 
of  the  eye,  359 
of  the  nose,  359 
of  the  throat,  359 
in  general  diseases,  357 
in  gynjecological  practice,  365 
in  inflammatory  conditions,  257 
in  tumours,  257 

less  virulent  cases  most  amenable  to  treat- 
ment, 384 
method  of  treatment,  346 
other   methods  of   treatment    not    to    be 
neglected    during    radiation    treat- 
ment, 384 
penetrating   power   of   the   ray   onl}'-   one 

factor,  381 
radiations  lead  to  constitutional  disturb- 
ance (reaction),  262 
the  skin  must  be  protected  in  treatment 

of  deep-seated  diseases,  258 
treatment  of  cancer  of  the  bladder,  377 
cancer  of  the  oesophagus,  374 
cancer  of  the  prostate  gland,  376 
cancer  of  the  rectum,  375 
cancer  of  the  tongue  and  mouth,  373 
carcinomata,  371,  372 
deep-seated    tumours    by  external    ap- 
plications, 352 
cautions  to  be  observed,  353 
diseases  of  the  skin,  361 
exposure,  361 
large  areas,  361 
exophthalmic  goitre,  360 
infiltrating  epithelioma,  370 
malignant  disease  of  the  thvroid  gland, 

360 
patients  in  hospital  or  at  their  homes,  358 
sarcomata,  371,  372 

superficial  epithehoma  and  rodent  ulcer, 
368 
tube  inserted  in  oesophageal  tube,  374,  375 

into  bowel,  376 
warning  against  too   hasty  assurance   of 
cure  by,  259 
Radium  and  mesothorium,  381 

and  oxygen,  for  inhalation,  346,  347 
and  X-rays,  combined  use  in  treatment  of 
malignant  disease,  378-385 
in  carcinoma  of  the  uterus,  382 


Radium   and    X-rays,   no    case    should   be 
refused  a  trial,  379 
effect  upon  rodent  ulcer,  P.  368 
X-rays  and  CO,,  effect  upon  rodent  ulcer, 
P.  300,  F.  311 
Radius,  development  of,  140 
fracture  of,  159,  161,  162 

investigations  of  cases,  162 
radiography  of,  134 

{see  also  Elbow-joint,  Forearm,  and  Wrist) 
Rectifier,  high  tension,  4,  5,  9 

for  valve  tubes,  51 
Rectum,  cancer  in,  treatment  by  radium,  375 

description  of,  232 
Regeneration    of   vacuum    of    X-ray   tubes, 

methods  used  for,  44 
Regulation  of  valve  tubes,  51 
Regulation  of  X-ray  tubes,  40,  42 

deciding  when  necessary,  43 
Regulator,  Bauer  air-valve,  46 
double,  45 
Gundelach,  47 
mica,  44,  45 
Resistance,  for  control  of  interrupter,  274 
Reverse  (inverse)  current  (see  Current) 
Rheostat,  series,  16 
Rheumatic  gout,  178 
Rheumatism,  chronic  articular,  177 
Rheumatoid  arthritis,  178 

changes  in  joints,  P.  176 
Ribs,  fracture  of,  157 
Rickets,  172 

Rieder,  Dr.,  cinematographic  demonstrations 
of  contractions  of  stomach,  219,  221 
exposure  stand,  79 

preparation  of  and  results  obtained  with 
opaque  meal,  215,  221 
Ringworm,  treated  by  X-rays,  299-301,  302 
Rontgen  rays  {see  X-rays) 
Rose  and  Carless,  example  of  fracture  of  neck 

of  scapula,  158 
Rosenthal,  cinematographic  demonstrations 
of  contractions  of  stomach,  219,  221 

Sabouraud  and  Noire  pastilles  for  dosage, 
279-292 

Bordier's  chromo-radiometer,  282 

Hampson's  radiometer,  290,  291 

Holzknecht's  quantimeter,  281 

light  for  examining,  280 

Lovibond's  tintometer,  288 

method  compared  with  liienbock,  285 
Sadler,    work    on    secondary    radiations    of 

metals,  254 
Salmond,  Dr.  R.  W.  A.,  investigations  by,  162 

investigation  regarding  X-ray  filters,  293 
Salvarsan,  injection  of,  255 
"  Sanax  "  interrupter,  81 
Sarcoma,  in  mediastinum  and  lungs,  P.  188 

of  bone,  183 

of  clavicle,  184 

of  femua,  182,  P.  183,  P.  186 

of  humerus,  P.  183,  P.  186 

of  the  lung,  199 

26 


402 


RADIOGEAPHY 


Sarcoma,  medullary,  187 
myeloid,  184 

recurrent,  treatment  with  radium,  371 
Sarcoma,   chrondo-,  of   lower   end  of   tibia, 

183 
Sarcomata  of  bone,  187 

of  lungs,  treatment  by  X-rays,  328 
treatment  by  radium,  371,  372 
treatment  by  X-rays,  312 
Sarcomatous  glands,  treatment  by  X-rays, 

308 
Scale,  comparative,  of  the  usual  instruments 
for  measuring  the   hardness   of   X-ray 
tubes,  61,  268 
showing  filter  equivalents,  293 
Scalp,  septic  condition,  treatment  by  X-rays, 
301 
tuberculous   condition,    treatment   by   X- 
rays,  301 
Scapula,  development  of,  138 
fracture  of,  157,  158 
acromion  process,  158 
body,  158 

coracoid  process,  158 
neck  of,  158 

Astley  Cooper,  South,  and  Rose  and 

Carless  on,  158 
case  at  Great  Northern  Central  Hos- 
pital, 159 
example  in  Guy's  Hospital  Museum, 

158 
first  authentic  case  of  (Spence),  159 
spine,  158 

{see  also  Shoulder-joint) 
Schonburg,  Dr.  Albers,  compressor,  237 
technique  in  treatment  of  uterine  fibromata, 
319 
uterine    myoma ta    and    climacteric 
troubles,  320 
Schwartz  capsule,  use  of,  222 

technique  for  use  of  bismuth  in  stomach, 
225 
Sclerosis  of  bone,  168 
Screen  examination  of  urinary  tract,  236 
Screen,  lead  lined,  for  protection  of  operator, 

79 
Screening  stands,  70-73 
Levy  born,  70,  71 
upright,  70,  71 

with  stereoscopic  movements,  189 
Wenckebach,  72,  73 
Secondary  radiations  of  metals,  254 

iron  stands  high  in  the  list,  254 
Secondary  rays,  54,  55 
Sector,  use  of,  78 
Selection  of  X-ray  tubes,  40 
Series  rheostat,  16 
Serous  pleural  effusion,  203 
Sesamoid  bones,  development  of,  153 
Shell,  portion  of,  in  hip-joint,  120 
in  limb,  121 
in  tibia,  121 
shrapnel,  in  hand,  121 
Shenton's  method  of  localisation,  115 


Shoulder-joint,  epiphj^ses  of,  151,  152 
exostosis  of  angle  of  scapula,  P.  156 
fracture  at  upper  end  of  shaft  of  humerus, 

P.  156,  P.  158 
fracture  of  clavicle,  P.  158 
fracture  through  great  tuberosity,  P.  156 
fracture  through  lower  aspect  of  glenoid 

cavity,  P.  158 
normal,  P.  135,  152 
radiography  of,  133,  134 
separation    of    the    great    tuberosity    of 

humerus,  P.  158 
tubercular  disease  of,  P.  175 
Single  impulse  current,  of  great  intensity,  6 
outfit,  7 

special  automatic  switch  for,  16 
radiographs,  apparatus  for,  5 
system,  7 

taking  radiographs  by,  8 
Skin,  effect  of  radium  upon,  256 

malignant  invasions  of,  treatment  by  X- 
rays,  305 
Skin  diseases,  treatment  by  radium,  361 
of  large  areas,  361 
use  of  Gamma  ray,  361 
treatment  by  X-rays,  298 
Skull,  development  of  bones  of,  143 
fracture  of  the  vault  of,  155 
from  a  case  of  tumour  of  the  brain,  P.  128 
injuries  of,  154-156 

localisation  of  foreign  bodies  in,  110-128 
(normal),  P.  124,  P.  126 
of  a  child,  P.  126,  P.  128 
showing  erosion  of  occipital  bone,  P.  128 
showing  good  detail  in  soft  parts,  P.  129 
SkuU  and  accessory  sinuses,  radiography  of, 
123 
Dr.  Martin  Berry's  chair  for,  123, 125 
Slide  rule,  92,  93 
Snook  apparatus,  9,  10,  126,  272 
South,  and  fracture  of  neck  of  scapula,  158 
Spark  gap,  48 

length,  14 
Spence,   first  authentic  case  of  fracture  of 

neck  of  scapula,  159 
Sphenoidal  sinuses,  radiography  of,  128 
Spine,  caries  of  cervical  vertebrae,  P.  179 

sacrum  and  lumbar  vertebrse,  P.  179 
curvature    of    lower    dorsal    and    lumbar 
vertebrse,  P.  179 
upper  dorsal,  P.  179 
dorsal,  radiography  of,  132 
injuries  of,  154,  156,  157 
lumbar,  radiography  of,  132 
normal  lumbar,  P.  133 
tumours  of,  197 
Spintermeter,  56 
Spleno-medullary   leukaemia,    treatment   by 

X-rays,  325 
Stereoscope,  Pirie,  106 
Stereoscopic  fluoroscopy,  106 
method  of  localisation,  118 

in  combination  with  Mackenzie  Davidson 
method,  119 


INDEX 


403 


Stereoscopic  negatives,  examination  of,  108, 
110,  111 
plates  siiould  bo  developed  together,  107 
radiography,  105 
Sternum,  development  of,  142 

radiography  of,  131 
Stokes-Adams  disease  of  heart,  205 
Stomach,  anatomy  of,  211 
atony  of,  225 
callous  ulcers,  224 
cancer  of,  227,  228 

cinematographic    demonstrations    of   con- 
tractions of,  219 
diagrams  showing  stages  of  filling,  213 
disturbance  of  secretion,  222 
effect  of  pressure  of  disease  in  other  organs, 

228 
empty,  212 
examination  of,  210 
exposure  for,  5 
full,  214 

functional  disturbances  of,  220 
half-filled,  212 
Hertz  description    of   three    positions  of, 

211-214 
Holzknecht's  grouping  of  radiographic  and 
clinical  results  of  bismuth  examination 
of,  219 
hour-glass    contraction    of,     223,    (inter- 
mittent) 225,  (true)  226,  (non-malig- 
nant) 226,  (malignant)  227 
"  magenblase  "  in,  214,  221,  226 
motility  of,  221 
opaque  meal  in,  214,  217 

variations  of,  and  results  obtained,  215 
patholosjical  changes  in  form  and  position 
of,  ^222 
conditions  of,  222 
penetrating  ulcer  in,  225 
position  of,  212 
pseudo  contractions  of,  225 
ptosis,  222 
pyloroptosis,  223 
radiographic  appearances  of,  219 
radioscopy  of,  precautions  necessary,  219 
Schwartz  technique  for  use  of  bismuth  in, 

225 
showing  hour-glass  contraction,  P.  226 
obstruction  at  pylorus,  P.  222,  P.  230 
pyloric  stenosis,  P.  213,  P.  226 
time  taken  to  empty,  221 
tumour  of,  228 
types  of,  220 
ulcer  of,  223 

variations  in  position  and  size  of,  220 
stomach  and  colon  showing  visceroptosis, 
P.  218,  P.  220 
opaque  meal  in,  P.  222 
Stone  (see  Calculi) 

Swallowing,  act  of,  radiographed,  6 
Sweat  glands,  effect  of  radium  upon,  257 
Sweet's  localiser,  123,  124 

for  the  eye  and  orbit,  118 

for  radiography  of  the  skull,  123 


Switchboard,  207 
Syphilis,  195,  202 

congenital,  171 

of  bone,  180 
Syphilitic  dactylitis,  180 

diseases  of  bone,  171 

lesions  of  skin,  chronic,  treatment  by  X- 
rays,  305 
Szillard,  the  lonto  quantimeter,  287 

Table  of  development  of  tarsus,  144 
of  carpal  bones,  149 
of  exposures  for  radiographs,  93 
with  radiometers,  94 
Marie  and  Ribaut's,  105 
Tachymeter,  271 

Tarsal  bones,  radiography  of,  136 
Tarsus,  table  of  development  of  the,  144 
Teeth,  examination  of,  by  radiography,  129 
Tele-Rontgenography,  76,  208 
Therapeutic  coil,  269 

doses  of  X-rays,   dipping  interrupter  for 

regulation  of,  271 
outfit  suitable  for  deep  therapy,  269 
tube,  choice  of,  294 
tube-stand,  275 
by  GaifEe,  275 

by  Dr.  GauSs  of  Freiburg,  276 
Therapeutics,  use  of  qualimeter,  57 
Thoracic  aneurism,  205 

area,  treatment  by  X-rays,  327 
Thorax  and  its  contents.  X-ray  examination 
of,  188-208 
bismuth  food  in,  211 
diseases  of,  194-197 
foreign  bodies  in,  197 
lateral  view  of,  211 
malignant  diseases  of,  196 
of  adult,  practically  normal,  190 
pyo-pneumo,  204 
radiography  of,  191-194 
radioscopy  of,  188 

routine  examination,  189 
technique  of  examination,  188-191 
results    obtained    at    Cancer    Hospital   in 
examination  of,  194 
Throat,  diseases  of,  treatment  by  radium,  359 
Tibia,  development  of,  141 
epiphyses  of,  145 
fractures  of,  147,  165 
radiography  of,  136 
(see  also  Leg) 
Tidy  and  Panton,   results   of  treatment   of 

blood  diseases  by  X-rays,  326 
Tissues,  effect  of  radiations  upon,  251,  252 
description  of  Plates  showing,  259-261 
normal,    changes    in,    due   to    radiations, 

P.  254 
normal,  radiations  upon,  256 
Tongue,  cancer  in,  treatment  by  radium,  373 
Tonsil,  carcinoma  of,  treatment  by  radium, 

370 
Transformer,  6 

Gaiffe-Rochefort,  3 


404 


EADIOGEAPHY 


Transformer,  high-tension,  9 

motor,  12 
Traumatic  myosotis  ossificans,  186 
Trichophytia,  treated  by  X-rays,  299-301,  302 
Trochanter,  great,  fracture  of,  165 
Tube  {see  Valve  tubes  and  X-ray  tubes) 
Tube-box,  63 

description  of,  64 
protected,  underneath  couch,  68 
Tube-stands,  62-78 
accessories,  65 
carrier,  65 
centering  device,  66 
compressor  diaphragm,  65 
holders,  66 

iris  diaphragm,  64,  66 
lead-glass  tubes,  66 
rectangular  diaphragm,  65 
shutter  diaphragm,  66 
instructions  for  use  of,  66 
pillar,  62,  63,  64,  65 

description  and  use  of,  62-66 
protected,  62,  63,  65 
universal  safety  and  protective,  73,  74 
sector  provided  for,  77 
Tubercular  dactylitis,  180 
Tuberculosis  in  joints,  appearance  of,  179 
of  the  heart,  195 
of  the  lungs,  195,  200 
sub-acute    or   chronic,    treatment    by    X- 
rays,  328 
Tuberculous  disease  of  bone,  170 

diseases  of  bones  and  joints,  P.  173,  P.  174, 

P.  175,  P.  181 
disease  of  the  kidney,  244 
epiphysitis,  170 

glands,  treatment  by  X-rays,  307 
Tuberculous  osteitis,  170 

periostitis,  170 
Tumour  cells,  action  of  radiations  upon,  258 

changes  induced  by  radiations,  382 
Tumours,    changes    in,    due    to    radiations, 
P.  256,  P.  258,  P.  260 
of  bone,  182,  P.  183,  P.  186 

differential  diagnosis  of,  185-187 
of  chest  walls,  197,  204 
of  clavicle,  184 
of  the  heart,  195,  196 
of  the  kidney,  245 
of  large  intestine,  233 
of  the  lungs,  196,  198 
of  the  mediastinum,  197 
of  the  oesophagus,  197 
of  the  pleura,  196 
of  the  spine,  197 
of  the  stomach,  228 

sections  of,  before  treatment  by  radiations, 
P.  260 
Tungsten    metal,    most    suitable    for    anti- 

cathode  of  X-ray  tubes,  8 
Turbinate  bones,  radiography  of,  128 
Turner,  Dawson,  expression  of  radium  dosage 
in  milligram-hours,  356 
formula  for  localisation,  113 


Turner,    Dawson,    record    of    treatment    of 

exophthalmic  goitre  by  radium,  360 
Typhoid  osteitis,  169,  170 

Ulcer,  chronic,  treatment  by  X-rays,  305 
of  stomach,  223 

rodent,  treatment  by  radium,  359,  P.  368 
radium  and  X-rays,  P.  368 
radium.  X-rays,  and  CO2,  P.  311 
X-rays,  309-311 
superficial,  310 
simple,  treatment  by  X-rays,  305 
situated    near    the    orbit,    treatment    by 
radium,  369 
Ulcerated  carcinoma,  treatment  by  X-rays, 

P.  314 
Ulna,  development  of,  139 
fracture  of,  159,  161,  162 

investigation  of  cases  of,  163 
radiography  of,  134 
(see  also  Forearm) 
Universal  examining  chair,  78,  79 

tube-stand,  73-74 
Ureters,  240 

calculi  in,  242,  243 
calculus  in,  P.  245 
collapse  of,  P.  245 
demonstration  of  with  collargol  solution, 

247 
occlusion  of,  246 
Urinary  calculi,  P.  241,  P.  244,  241-244 
organs,  anatomical  relations  of,  239 

diagram  of  areas  to  be  radiographed,  239 
system,    technique    of    examination    with 
collargol  solution,  247 
dangers  arising  from  the  use  of  collargol, 

247 
demonstration  of  the  ureter,  247 
position  of  the  patient,  247 
strength  of  solution  employed,  247 
tract,  diseases  of,  240 

X-ray  examination  of,  235 

examination  of  the  patient,  236 
screen  and  radiographic,  236 
technique,  235 

preparation  of  the  patient,  235 
Uterine    fibroids,    Bordier    technique    with 
X-rays,  321 
Haenisch  technique  with  X-rays,  320 
incident  dose  of  X-rays  for,  322 
use  of  Kienbock  slips  when  treating  by 
X-rays,  323 
Uterine    fibromata,     techniques    of    Albers 
Schonberg,  Haenisch,  Boi'dier,  and  mem- 
bers of  Freiburg  School,  319 
treatment  by  X-rays,  318 
Uterine  fibromyomata,  treatment  by  X-rays, 

315 
Uterine   myomata,   Albers   Schonberg   tech- 
nique with  X-rays,  320 
Uterine  sound,  a,  for  application  of  radium, 

365,  366 
Uterus,  carcinoma  of  the,  combined  use  of 
radium  and  X-rays,  382 


INDEX 


405 


Valve  tubes,  48,  50,  207,  209 

American,  52 

French,  51 

Gundelach,  52 

high-tension  rectifier  for,  51 

in  series,  50 

Oliver  Lodge,  51 

regulation  of,  51 

should  never  be  worked  "  hard,"  52 

triple,  27S 

use  of,  274 
Vascular  connective  tissue,  effect  of  radium 

upon,  257 
Verrucse    vulgari,     treatment     by     X-rays, 

304 
Vertebraj   {see  Spine,   Cervical,   Dorsal,  and 

Lumbar) 
Vertebral  column,  development  of  bones  of, 

143 
Visceroptosis  (see  Stomach) 

Walsham,  description  of  case  of  fracture  of 

neck  of  scapula,  158 
Walter's  radiometer,  58,  59,  61 
Walter-Benoist  radiometer,  59,  61 
Warts,  treatment  by  radium,  363 

treatment  by  X-rays,  304 
Wassermann  reaction,  202 
Water-cooled  tubes  (see  X-ray  tubes) 
Waters,  radio-active,  260 
Wehnelt's  crypto -radiometer,  59,  60,  61 

interrupter,  6 
Wernekros,  Professor,  results  of  experiments 

with  radiations,  380 
Wheatstone  localiser,  108 

stereoscope,  106 
Wickham,  early  work  in  radium  therapy,  251 
on  changes  which  occur  in  radium  therapy, 
257,  258 
Wolff  and  Melchener,  experiments  regarding 

action  of  X-rays  upon  blood,  326 
Wrist,  CoUes  fracture,  P.  163 

chronic  osteitis  after  injury  to,  P.  171 
displaced  epiphyses  of  lower  end  of  radius, 

P.  164 
fracture  of  trapezium,  P.  162 

of  lower  end  of  radius,  P.  163 
separated  epiphysis  of  lower  end  of  radius, 
P.  163 
Wrist-joint,  epiphyses  of,  148,  149 
injuries  at,  162 
radiography  of,  134 

X-rays,  action  of  radiations  upon  tissues,  252 
an  important  therapeutic  agent,  383 
apparatus  arranged  on  upright  cabinet,  277 
caution  regarding,  95 
comparison  of  units  of  measurement  for 

dosage,  321 
couch  with  compressor,  237 
cubicle,  266 

dangers  attendant  on  the  use  of,  263 
late  manifestations,  264 
intensive  treatment,  264 


X-rays,  degree    of   penetration,    instrument 
for  measuring,  59,  60 
diaphragms  for  suppression  of  secondary 

rays,  54,  55 
dipping  interrupter  for  regulation  of  thera- 
peutic doses,  271 
effect    upon    recurrent    carcinoma    after 
operation,  P.  372 
ulcerated  carcinoma,  P.  314 
employment  in  therapeutics,  hardest  rays 

give  best  results,  252,  254 
erythema  dose  in  therapeutics,  57,  58 
examination  of  thorax  and  its  contents, 
188-208 
of  urinary  tract,  235 

examination  of  the  patient,  236 
preparation  of  the  patient,  235 
rapid  radiographic  exposure,  236 
screen  examination,  236 
technique  of,  235 
importance  of,  in  relation  to  diagnosis  of 

cancer,  227 
installation ;    it  is  advisable  to   wire  for 

larger  capacity  than  is  required,  3 
installation,  for  a  general  hospital,  82 
for  a  consulting  radiologist,  82 
for  a  special  hospital,  85 
for  a  base  hospital  (military),  87 
portable,  for  a  collecting  hospital  (mili- 
tary), 88,  89 
field  outfit,  90 
small,  80,  81 
intensity  of,  92 

varies     with     distance     between     anti- 
cathode  and  plate  or  object,  94 
measurement  of  by  milliamperemeter,  60 
method  of  connecting  valve  to  tube,  275 
observations  on  blood  changes  induced  by, 

253 
production  of,  39 
protected  tube-box,  278 
radiations   always   lead   to   constitutional 

disturbance,  262 
secondary,  69 

secondary  radiation,  cause  of,  54 
diagram  illustrating,  54 
methods  of  suppression,  54,  55 
technique  for  exposures  with  qualimeter, 

58 
testing  the  apparatus,  278 
X-ray  therapeutics,  251-328 
advance  in  technique,  378 
arrangement  of  apparatus,  267-278,   276, 

277 
changes  induced  in  tumour  cells,  382 
choice  of  tube,  294 
control  apparatus,  266 
early  work,  265 
filter  equivalents,  293 
filters,  additional,  293 
selection  of,  293 
use  of,  292 
heavy    doses,    important    points    regard- 
ing, 381 


406 


RADIOGRAPHY 


X-ray  therapeutics,  less  virulent  cases  are 
more  amenable  to  treatment,  384 
methods  of  protection  for  workers,  265 
methods  used  in  estimation  of  dosage — 
indirect,  278 
direct,  279 
other  methods  of  treatment  not  to  be 
neglected  during  radiation  treatment, 
384 
penetrating  power  of  the  ray  only  one 

factor,  381 
record  of  exposures,  287 
Sabouraud  and  other  pastilles,  279-292 

light  for  examining,  280 
special  points  for  instrumentation,  265 
testing  the  apparatus,  278 
treatment  couch,  276 

stand,  276 
treatment  of  cancer,  292 

of  carcinoma  of  the  mammae,  382 
of  carcinomata,  312 
before  operation,  313 
inoperable,  315 
post-operative,  313 
recurrent,  316 
results  of  prophylactic,  314 
of  diseases  of  the  blood,  323-327 
action  of  X-rays,  326 
blood  change  desired,  327 
of    diseases  of   the  lungs  and  medi- 
astinum, 327,  328 
technique,  328 
of  enlarged  lymphatic  glands,  307-309 
of  enlargement  of  prostate  gland,  316 

technique,  317 
of  epitheliomata,  312 
of  exophthalmic  goitre,  317 
object  of  treatment,  318 
of  leukaemia,  252 
of    malignant    disease   of    the   pelvic 

organs,  379 
of  mediastinal  cancer,  382 
of|  non-malignant  neoplasms,  378 
of  ringworm,  dosage  for,  280 
of  rodent  ulcers,  309-311 
after  ulcer  has  healed,  311 
distinction  from  epithelioma,  311 
if  ulcer  increases,  311 
of  sarcomata,  312 
of  simple  ulcers,  305 
of  skin  diseases,  298-305 

chronic  conditions  benefit  most  by, 

298 
technique  and  data,  298 
of  uterine  fibromata,  318 
X-ray  tubes,  air-cooled,  34 
American,  35-39,  126 
Coolidge,  35-38,  94,  95,  269,  294 

battery  for,  37 
Cyclops  radiator,  iO 
Dessaeur,  M,  296 


X-ray  tubes,  Gundelach,  35 
Gundelach  valve,  52 
Macalaster  Wiggin,  295 
Miiller,  238 
Penetrans,  295,  296 
water-cooled,  296,  321 
advantages  of,  32 
Miiller,  31,  32 
principal  feature  of,  32 
selection  of,  32 
use  of,  33 
X-ray  tubes  and  accessories,  28 
anti-cathode,  the,  29,  39 
appearance  of,  in  auction,  frontispiece,  40 
arrangement  for  water  cooling,  294 
blackening  of,  49 
box,  efficiently  protected,  278 
choice  of,  for  therapeutic  work,  294 
connections,  15 
connections  to  the  coil,  40 
description  of  manufacture,  29 
diagram  of,  28 
distance  from  subject,  92 
focus  tube,  the,  28 
for  heavy  currents,  296,  297 
for  superficial  work,  295 
hardness   of,   instruments  for  estimating, 
55,  58,  59 
comparative  scale,  61,  268 
management  of,  for  good  radiographs,  238 
manipulation  of,  43 
method  of  operating,  38 
methods  used  for  cooling,  297 
regeneration  of  vacuum,  44 
overheating,  49 
quality  of,  for  radiographs,  92 
radiator  tube  for  heavy  discharges,  29 
regulation  of,  40,  42 

deciding  when  necessary,  43 
regulator,  Bauer  air-valve,  46 
Gundelach,  47 
mica,  44,  45 
selection  of,  40 

several  should  be  in  use,  41,  238 
stand  for  deep  therapeutic  work,  275 
too  hard  for  regulation,  42 
work  by  Barkla,  Sadler,  and  Hernemann 
Johnson   on  secondary  radiations  of 
metals,  254 
X-rays  and  radium,  combined  use  in  treat- 
ment of  malignant  disease,  378-385 
effect  upon  rodent  ulcer,  P.  368 
in  carcinoma  of  the  uterus,  382 
malignant  disease,  378-385 
no  case  should  be  refused  a  trial,  379 
X-rays,  radium,  and  CO2,  effect  upon  rodent 
ulcer,  P.  309,  P.  311 

Ziegler,  explanation  of  action  of  X-rays  in 

blood  diseases,  326 
Zygomatic  arch,  fractures  of,  156 


Printed  by  R.  &  R.  Clark,  Limited,  Edinbtcrgh. 


RC78 
Knox 


K77 
Copy  2 


1^ „^.u. 


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